Provider Demographics
NPI:1861635690
Name:KISELICA, PAMELA JOY
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JOY
Last Name:KISELICA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 10TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:FL
Mailing Address - Zip Code:32052-5844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:406 10TH AVE NW
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:FL
Practice Address - Zip Code:32052-5844
Practice Address - Country:US
Practice Address - Phone:386-792-1338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator