Provider Demographics
NPI:1750042081
Name:KISHI, LAURA ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:KISHI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PROFESSIONAL CENTER DR STE 523
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-4361
Mailing Address - Country:US
Mailing Address - Phone:415-308-4718
Mailing Address - Fax:
Practice Address - Street 1:500 PROFESSIONAL CENTER DR STE 523
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-4361
Practice Address - Country:US
Practice Address - Phone:415-308-4718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-08
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019558363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner