MEDICARE: MRS. STACY NICOLE KISOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SI 60298212	WA

General Provider Information

NPI Number	:	1770829061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACY NICOLE KISOR

Provider Business Mailing Address
First Line	:	5516 S FORT APACHE RD STE 130
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-7679
Country	:	US
Telephone Number	:	702-641-8255
Fax Number	:	702-399-8255

Provider Business Practice Location Address
First Line	:	5516 S FORT APACHE RD STE 130
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-7679
Country	:	US
Telephone Number	:	702-641-8255
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2012
Last Update Date	:	02/26/2020

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