Provider Demographics
NPI:1285473876
Name:KISOR, MANDY LEANN (FNP-C)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:LEANN
Last Name:KISOR
Suffix:
Gender:F
Credentials:FNP-C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:14 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-4381
Practice Address - Country:US
Practice Address - Phone:770-749-5400
Practice Address - Fax:770-749-9628
Is Sole Proprietor?:No
Enumeration Date:2024-05-22
Last Update Date:2024-09-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GAGAA-NP002532363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner