MEDICARE: MARY KAY NISSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	A-076138	IA

General Provider Information

NPI Number	:	1659604403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY KAY NISSEN

Provider Business Mailing Address
First Line	:	3303 REBECCA ST
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51104-2324
Country	:	US
Telephone Number	:	712-279-5458
Fax Number	:

Provider Business Practice Location Address
First Line	:	3303 REBECCA ST
Second Line	:
City	:	SIOUX CITY
State	:	IA
Zip	:	51104-2324
Country	:	US
Telephone Number	:	712-279-5458
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2009
Last Update Date	:	10/03/2023

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Directions to “ MARY KAY NISSEN ” Practice Location

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