Healthcare Provider Details

I. General information

NPI: 1487057568
Provider Name (Legal Business Name): LARA ELAINE KISER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 COLLEGE RIDGE ROAD
CEDAR BLUFF VA
24609-0765
US

IV. Provider business mailing address

PO BOX 765
CEDAR BLUFF VA
24609-0765
US

V. Phone/Fax

Practice location:
  • Phone: 276-964-7176
  • Fax: 276-964-7157
Mailing address:
  • Phone: 276-964-7176
  • Fax: 276-964-7157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024172068
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: