Provider Demographics
NPI:1225219009
Name:KISNER, WALTINA J (MSN, APN)
Entity type:Individual
Prefix:
First Name:WALTINA
Middle Name:J
Last Name:KISNER
Suffix:
Gender:F
Credentials:MSN, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 S NATIONAL AVE STE 440
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7304
Mailing Address - Country:US
Mailing Address - Phone:417-888-5660
Mailing Address - Fax:
Practice Address - Street 1:3231 S NATIONAL AVE STE 440
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7304
Practice Address - Country:US
Practice Address - Phone:417-888-5660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO140376363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1225219009Medicaid
MO431560263OtherTRICARE WEST
P00826746OtherRAILROAD MCR CB9013
AR183029758Medicaid
MO1225219009Medicaid
MO431560263OtherTRICARE WEST