Provider Demographics
NPI:1992577233
Name:KISSINGER, KANDICE (FNP)
Entity type:Individual
Prefix:MRS
First Name:KANDICE
Middle Name:
Last Name:KISSINGER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:KANDICE
Other - Middle Name:KACHET
Other - Last Name:MC NEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:3034 W LOGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5707
Mailing Address - Country:US
Mailing Address - Phone:708-928-0188
Mailing Address - Fax:
Practice Address - Street 1:1953 W WABANSIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1343
Practice Address - Country:US
Practice Address - Phone:312-313-7477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017143363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner