Provider Demographics
NPI:1558832758
Name:RICKARD, KISANDRA LEIGH (APRN)
Entity type:Individual
Prefix:
First Name:KISANDRA
Middle Name:LEIGH
Last Name:RICKARD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15004
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37901-5004
Mailing Address - Country:US
Mailing Address - Phone:865-541-8895
Mailing Address - Fax:865-633-4808
Practice Address - Street 1:1610 TAZEWELL ROAD SUITE 203
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37879-3648
Practice Address - Country:US
Practice Address - Phone:423-259-3701
Practice Address - Fax:866-954-5783
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29250363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ087307Medicaid