Provider Demographics
NPI:1992519649
Name:HISSONG, KATHRYN MARIE (ACAGNP-BC)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARIE
Last Name:HISSONG
Suffix:
Gender:F
Credentials:ACAGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2980 ARBORVITAE DR APT 2
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-6706
Mailing Address - Country:US
Mailing Address - Phone:810-869-1754
Mailing Address - Fax:
Practice Address - Street 1:2980 ARBORVITAE DR APT 2
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49685-6706
Practice Address - Country:US
Practice Address - Phone:810-869-1754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704278432363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care