Provider Demographics
NPI:1790156578
Name:KANNEBECKER, ISE (CRNP)
Entity Type:Individual
Prefix:
First Name:ISE
Middle Name:
Last Name:KANNEBECKER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-1445
Mailing Address - Country:US
Mailing Address - Phone:570-253-8226
Mailing Address - Fax:570-253-8228
Practice Address - Street 1:412 COMO RD
Practice Address - Street 2:
Practice Address - City:LAKE COMO
Practice Address - State:PA
Practice Address - Zip Code:18437-1020
Practice Address - Country:US
Practice Address - Phone:570-798-2828
Practice Address - Fax:570-798-2636
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP015305363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner