Provider Demographics
NPI:1952968273
Name:KINGSLAND, MISTICA JO (LPN, CMS, QMHS)
Entity type:Individual
Prefix:
First Name:MISTICA
Middle Name:JO
Last Name:KINGSLAND
Suffix:
Gender:
Credentials:LPN, CMS, QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 STONERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-8956
Mailing Address - Country:US
Mailing Address - Phone:740-500-1391
Mailing Address - Fax:
Practice Address - Street 1:2065 STONERIDGE DR
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-8956
Practice Address - Country:US
Practice Address - Phone:740-500-1391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
OH106602IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator