Provider Demographics
NPI:1124734157
Name:NISLY, J MARK (CRNP)
Entity type:Individual
Prefix:
First Name:J
Middle Name:MARK
Last Name:NISLY
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3148 LINCOLN HWY E
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:PA
Mailing Address - Zip Code:17562-9601
Mailing Address - Country:US
Mailing Address - Phone:620-694-7624
Mailing Address - Fax:
Practice Address - Street 1:500 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2360
Practice Address - Country:US
Practice Address - Phone:717-531-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP026545363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine