Provider Demographics
NPI:1730487877
Name:KISSLER, SARALYSE CHANTEL (LAC)
Entity Type:Individual
Prefix:
First Name:SARALYSE
Middle Name:CHANTEL
Last Name:KISSLER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 SAN JOSE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-6218
Mailing Address - Country:US
Mailing Address - Phone:831-234-9381
Mailing Address - Fax:
Practice Address - Street 1:1220 41ST AVE
Practice Address - Street 2:SUITE I
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-3933
Practice Address - Country:US
Practice Address - Phone:831-406-1319
Practice Address - Fax:831-462-2357
Is Sole Proprietor?:No
Enumeration Date:2011-03-13
Last Update Date:2011-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13342171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist