Basic Information
| Provider Information | |||||||||
| NPI: | 1174833867 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KNISLEY | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 637735 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452637735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138911006 | ||||||||
| FaxNumber: | 5137931032 | ||||||||
| Practice Location | |||||||||
| Address1: | 1402 N HIGH ST | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451338514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373934899 | ||||||||
| FaxNumber: | 9373934996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2010 | ||||||||
| LastUpdateDate: | 10/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | COA.11618-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3106794 | 05 | OH | MEDICAID |