Healthcare Provider Details

I. General information

NPI: 1376234641
Provider Name (Legal Business Name): LORI MICHELLE KISTLER PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 MULBERRY ST SW
LENOIR NC
28645-5722
US

IV. Provider business mailing address

407 MULBERRY ST SW
LENOIR NC
28645-5722
US

V. Phone/Fax

Practice location:
  • Phone: 828-394-6722
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberKIST-8232Y
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: