Provider Demographics
NPI:1982702304
Name:KISELIS, ILZE (MSRD LDN)
Entity type:Individual
Prefix:
First Name:ILZE
Middle Name:
Last Name:KISELIS
Suffix:
Gender:F
Credentials:MSRD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 NEPONSET ST FL STREET12
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2714
Mailing Address - Country:US
Mailing Address - Phone:508-852-6175
Mailing Address - Fax:508-595-2123
Practice Address - Street 1:5 NEPONSET ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-2714
Practice Address - Country:US
Practice Address - Phone:508-852-6175
Practice Address - Fax:508-595-2123
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA632133V00000X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
67853OtherFALLON COMMUNITY HEALTH P
LD0139OtherBLUE CROSS
042472266OtherPRIVATE HEALTHCARE SYSTEM
AA16844OtherHARVARD PILGRIM HEALTHCAR
042472266OtherTHREE RIVERS
7001600OtherAETNA US HEALTHCARE
LD0139OtherBLUE CROSS
7001600OtherAETNA US HEALTHCARE