Provider Demographics
NPI:1134753825
Name:WISNASKY, KRYSTLE MICHELLE (FNP-BC)
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:MICHELLE
Last Name:WISNASKY
Suffix:
Gender:
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14369
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63178-4369
Mailing Address - Country:US
Mailing Address - Phone:314-567-6071
Mailing Address - Fax:
Practice Address - Street 1:6812 STATE ROUTE 162 STE 200
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8562
Practice Address - Country:US
Practice Address - Phone:618-288-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.020939363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.020939Medicaid