Provider Demographics
NPI:1922257278
Name:KISE, LISA A (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:KISE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:KISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-8021
Mailing Address - Country:US
Mailing Address - Phone:860-679-4477
Mailing Address - Fax:860-679-1017
Practice Address - Street 1:275 W COCOA BEACH CSWY
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3529
Practice Address - Country:US
Practice Address - Phone:321-799-7777
Practice Address - Fax:321-799-1550
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1054593163W00000X
KY5673P363L00000X, 363LF0000X
CT008855363LF0000X
KY3005673363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100058130Medicaid
KY0319630Medicare PIN