Provider Demographics
NPI:1215672795
Name:BISE, MALISSA M (LPN)
Entity type:Individual
Prefix:
First Name:MALISSA
Middle Name:M
Last Name:BISE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MALISSA
Other - Middle Name:M
Other - Last Name:THACKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:RITTMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44270-1517
Mailing Address - Country:US
Mailing Address - Phone:234-249-9286
Mailing Address - Fax:
Practice Address - Street 1:201 N STATE ST
Practice Address - Street 2:
Practice Address - City:RITTMAN
Practice Address - State:OH
Practice Address - Zip Code:44270-1517
Practice Address - Country:US
Practice Address - Phone:234-249-9286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH122499164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse