Provider Demographics
NPI:1851581128
Name:KISER, KELLY LYNNE (NNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNNE
Last Name:KISER
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:WAGNER-GULISH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NNP
Mailing Address - Street 1:19016 E HUNT HWY
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85242-9247
Mailing Address - Country:US
Mailing Address - Phone:602-909-9541
Mailing Address - Fax:
Practice Address - Street 1:19016 E HUNT HWY
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85242-9247
Practice Address - Country:US
Practice Address - Phone:602-909-9541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAPN 74363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal