Provider Demographics
NPI:1780216523
Name:GISSE, KAITLYN (PA)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:GISSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:STOUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1280 E CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-3803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:321 E WARWICK DR
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1013
Practice Address - Country:US
Practice Address - Phone:989-466-3332
Practice Address - Fax:989-466-6805
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010222363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant