Healthcare Provider Details

I. General information

NPI: 1801389556
Provider Name (Legal Business Name): HEATHER DEANN KISSEL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2018
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S J ST
TACOMA WA
98405-4933
US

IV. Provider business mailing address

1717 S J ST
TACOMA WA
98405-4933
US

V. Phone/Fax

Practice location:
  • Phone: 253-426-6341
  • Fax: 253-426-6344
Mailing address:
  • Phone: 253-426-6341
  • Fax: 253-426-6344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOP61209052
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number009222
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberOP61209052
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: