Provider Demographics
NPI:1942485891
Name:SISTERMAN, KATHRYN (DNP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:SISTERMAN
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-367-4096
Mailing Address - Fax:
Practice Address - Street 1:1055 N CURTIS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1309
Practice Address - Country:US
Practice Address - Phone:208-367-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-09
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA643423163W00000X
AZ161452163W00000X
MI4704244332163W00000X
AZ7710363LA2100X
CA17433363LF0000X
AZ3577363LF0000X
ID59073363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily