Basic Information
Provider Information | |||||||||
NPI: | 1063787885 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KISLING | ||||||||
FirstName: | GAIL | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S., CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KISLING | ||||||||
OtherFirstName: | GAIL | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CCC-SLP | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 3378 LEROY DR | ||||||||
Address2: |   | ||||||||
City: | AMMON | ||||||||
State: | ID | ||||||||
PostalCode: | 834064537 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2085425372 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 393 E 2ND N | ||||||||
Address2: |   | ||||||||
City: | REXBURG | ||||||||
State: | ID | ||||||||
PostalCode: | 834401605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083599570 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/12/2012 | ||||||||
LastUpdateDate: | 07/30/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP-1254 | ID | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.