Healthcare Provider Details

I. General information

NPI: 1124435094
Provider Name (Legal Business Name): SHAWN KISE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2014
Last Update Date: 06/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 PIEDMONT AVE SUITE 4000
CINCINNATI OH
45219-4231
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTIALING
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-475-8521
  • Fax:
Mailing address:
  • Phone: 513-245-3104
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.313227
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCOA.16198-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: