Provider Demographics
NPI:1306106745
Name:LIESE, KYLEA (PHD CNM)
Entity type:Individual
Prefix:PROF
First Name:KYLEA
Middle Name:
Last Name:LIESE
Suffix:
Gender:F
Credentials:PHD CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-8151
Mailing Address - Country:US
Mailing Address - Phone:312-770-2336
Mailing Address - Fax:
Practice Address - Street 1:2233 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622
Practice Address - Country:US
Practice Address - Phone:312-770-2336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-18
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife