Provider Demographics
NPI:1578041760
Name:KISSELBURG, MAGGIE AMANDA
Entity Type:Individual
Prefix:MRS
First Name:MAGGIE
Middle Name:AMANDA
Last Name:KISSELBURG
Suffix:
Gender:F
Credentials:
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 158
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:71852-0158
Mailing Address - Country:US
Mailing Address - Phone:870-455-0134
Mailing Address - Fax:
Practice Address - Street 1:508 N 2ND ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-3925
Practice Address - Country:US
Practice Address - Phone:870-455-0134
Practice Address - Fax:870-277-2230
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator