Provider Demographics
NPI:1821262288
Name:ISON, KATHLEEN (IND PROV)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:ISON
Suffix:
Gender:F
Credentials:IND PROV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12310 BUTTERS RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133-7792
Mailing Address - Country:US
Mailing Address - Phone:937-466-2110
Mailing Address - Fax:937-466-2110
Practice Address - Street 1:12310 BUTTERS RD
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-7792
Practice Address - Country:US
Practice Address - Phone:937-466-2110
Practice Address - Fax:937-466-2110
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2012388Medicaid