Provider Demographics
NPI:1487670139
Name:KISS, PENELOPE (NP)
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:
Last Name:KISS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 566
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-0566
Mailing Address - Country:US
Mailing Address - Phone:616-975-1845
Mailing Address - Fax:616-975-1870
Practice Address - Street 1:300 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3307
Practice Address - Country:US
Practice Address - Phone:269-963-5048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704105112363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN34250001Medicare ID - Type Unspecified