Provider Demographics
NPI:1790158723
Name:KIESLING, PATRICE DORISMOND (FNP-C)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:DORISMOND
Last Name:KIESLING
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 E WOODMEN RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-8075
Mailing Address - Country:US
Mailing Address - Phone:719-632-4455
Mailing Address - Fax:197-633-4613
Practice Address - Street 1:4190 E WOODMEN RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-8075
Practice Address - Country:US
Practice Address - Phone:719-632-4455
Practice Address - Fax:719-633-4316
Is Sole Proprietor?:No
Enumeration Date:2015-11-13
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0992068-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO468608ZJNOtherMEDICARE PTAN
CO98720091Medicaid