Provider Demographics
NPI:1598122517
Name:KISER, PHYLLIS JOANN
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:JOANN
Last Name:KISER
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 1:7006 MASONBORO DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37174-6239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:124 BELLEVUE AVE E
Practice Address - Street 2:UNIT 504
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-5599
Practice Address - Country:US
Practice Address - Phone:615-497-2177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-21
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42979225100000X, 225100000X
TN10021225100000X
WA60632555225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist