Provider Demographics
NPI:1306294707
Name:WASHINGTON, KISSIE SHANTA
Entity type:Individual
Prefix:MS
First Name:KISSIE
Middle Name:SHANTA
Last Name:WASHINGTON
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 1:21504 WHITTINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-5763
Mailing Address - Country:US
Mailing Address - Phone:313-495-2717
Mailing Address - Fax:
Practice Address - Street 1:21504 WHITTINGTON ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5763
Practice Address - Country:US
Practice Address - Phone:313-495-2717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other