Provider Demographics
NPI:1528741436
Name:KISAMO, HAIKA GLORIA
Entity type:Individual
Prefix:
First Name:HAIKA
Middle Name:GLORIA
Last Name:KISAMO
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 1:5323 WHITEHAVEN PARK LN SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5957
Mailing Address - Country:US
Mailing Address - Phone:832-818-0877
Mailing Address - Fax:
Practice Address - Street 1:811 KENNESAW AVE NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1002
Practice Address - Country:US
Practice Address - Phone:770-422-2451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN270976363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care