Provider Demographics
NPI:1558832758
Name:RICKARD, KISANDRA LEIGH (APRN)
Entity Type:Individual
Prefix:
First Name:KISANDRA
Middle Name:LEIGH
Last Name:RICKARD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 SHARP LN
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37879-5300
Mailing Address - Country:US
Mailing Address - Phone:419-584-8865
Mailing Address - Fax:
Practice Address - Street 1:304 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-3617
Practice Address - Country:US
Practice Address - Phone:423-437-8612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH363LP0200X363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics