Provider Demographics
NPI:1124435094
Name:KISE, SHAWN
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:KISE
Suffix:
Gender:M
Credentials:
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 636256
Mailing Address - Street 2:CENTRAL CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-245-3104
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:222 PIEDMONT AVE
Practice Address - Street 2:SUITE 4000
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-4231
Practice Address - Country:US
Practice Address - Phone:513-475-8521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-12
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.313227163W00000X
OHCOA.16198-NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0109068Medicaid