Provider Demographics
NPI:1104881622
Name:KNISELY, KRISTINA L (MD)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:L
Last Name:KNISELY
Suffix:
Gender:F
Credentials:MD
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1301 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-8968
Practice Address - Country:US
Practice Address - Phone:270-765-2107
Practice Address - Fax:270-769-9642
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32107208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
008892OtherSIHO / NCMA
KY64321078Medicaid
2435270000OtherPASSPORT ADVANTAGE / NCMA
000023044BOtherHUMANA / NCMA
00000065596OtherANTHEM / NCMA
1076419OtherPASSPORT / NCMA
2192467001OtherCIGNA / NCMA
2435270000OtherPASSPORT ADVANTAGE / NCMA
KY64321078Medicaid