Provider Demographics
NPI:1770829061
Name:KISOR, STACY NICOLE
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:NICOLE
Last Name:KISOR
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 1:5516 S FORT APACHE RD STE 130
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-7679
Mailing Address - Country:US
Mailing Address - Phone:702-641-8255
Mailing Address - Fax:702-399-8255
Practice Address - Street 1:5516 S FORT APACHE RD STE 130
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-7679
Practice Address - Country:US
Practice Address - Phone:702-641-8255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-14
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASI 60298212235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist