Provider Demographics
NPI:1215654710
Name:ISON, KIMBERLY ANN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:ISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 PLYMOUTH RD APT T4
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1470
Mailing Address - Country:US
Mailing Address - Phone:734-589-7274
Mailing Address - Fax:
Practice Address - Street 1:25325 FORD RD STE 200
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48128-1086
Practice Address - Country:US
Practice Address - Phone:313-887-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704303316363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily