Provider Demographics
NPI:1659604403
Name:NISSEN, MARY KAY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:NISSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KAY
Other - Last Name:STUDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP-BC
Mailing Address - Street 1:3303 REBECCA ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-2324
Mailing Address - Country:US
Mailing Address - Phone:712-279-5458
Mailing Address - Fax:
Practice Address - Street 1:3303 REBECCA ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-2324
Practice Address - Country:US
Practice Address - Phone:712-279-5458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-076138363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner