Provider Demographics
NPI:1952533317
Name:KISELEVA, IRINA LEONIDOVNA (NP)
Entity Type:Individual
Prefix:MS
First Name:IRINA
Middle Name:LEONIDOVNA
Last Name:KISELEVA
Suffix:
Gender:F
Credentials:NP
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 1188
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 ELM ST SW STE 200
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1957
Practice Address - Country:US
Practice Address - Phone:541-812-4850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-19
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200950029NP363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR200950029NPOtherSTATE LICENSE