Provider Demographics
NPI:1013164292
Name:KISALA, YANNA T (OD)
Entity type:Individual
Prefix:DR
First Name:YANNA
Middle Name:T
Last Name:KISALA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203A E SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-7603
Mailing Address - Country:US
Mailing Address - Phone:262-524-1130
Mailing Address - Fax:
Practice Address - Street 1:203A E SUNSET DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-7603
Practice Address - Country:US
Practice Address - Phone:262-524-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3137-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist