Provider Demographics
NPI:1891502340
Name:KISSEE, AMELIA BROOKE
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:BROOKE
Last Name:KISSEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMELIA
Other - Middle Name:BROOKE
Other - Last Name:SEILER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:121 UNIVERSITY DR N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4631
Mailing Address - Country:US
Mailing Address - Phone:707-672-3805
Mailing Address - Fax:
Practice Address - Street 1:121 UNIVERSITY DR N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4631
Practice Address - Country:US
Practice Address - Phone:707-672-3805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ND175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator