Provider Demographics
NPI:1699792770
Name:KISPERT, MARY BETH (CRNA)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BETH
Last Name:KISPERT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:BETH
Other - Last Name:MUENCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:9207 N TENNYSON DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-1465
Mailing Address - Country:US
Mailing Address - Phone:414-352-9080
Mailing Address - Fax:
Practice Address - Street 1:5000 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295-0001
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:414-384-2939
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI80012367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered