Healthcare Provider Details

I. General information

NPI: 1467986703
Provider Name (Legal Business Name): LISA KISLING THOMPSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA ANN KISLING

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 03/27/2023
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W 86TH ST
NEW YORK NY
10024-3444
US

IV. Provider business mailing address

14286 BEACH HEATHER CT
PENSACOLA FL
32507-9712
US

V. Phone/Fax

Practice location:
  • Phone: 646-863-1411
  • Fax:
Mailing address:
  • Phone: 719-310-2117
  • Fax: 859-545-5035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0063179
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberC0426
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: