MEDICARE: MIKAYLA KISH CRNP

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	SP024440	PA

General Provider Information

NPI Number	:	1770253304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKAYLA KISH CRNP

Provider Business Mailing Address
First Line	:	1605 N CEDAR CREST BLVD STE 110B
Second Line	:
City	:	ALLENTOWN
State	:	PA
Zip	:	18104-2351
Country	:	US
Telephone Number	:	610-973-1410
Fax Number	:	610-973-1449

Provider Business Practice Location Address
First Line	:	6081 HAMILTON BLVD STE 101
Second Line	:
City	:	WESCOSVILLE
State	:	PA
Zip	:	18106-9801
Country	:	US
Telephone Number	:	610-395-0600
Fax Number	:	610-395-9473

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

Provider Enumeration Date	:	09/15/2021
Last Update Date	:	10/24/2024

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