Basic Information
| Provider Information | |||||||||
| NPI: | 1558531368 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KISH | ||||||||
| FirstName: | TRENA | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 97 GREAT TEAYS BLVD STE 6 | ||||||||
| Address2: | |||||||||
| City: | SCOTT DEPOT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255609816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047576999 | ||||||||
| FaxNumber: | 3042015019 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 251301417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043690393 | ||||||||
| FaxNumber: | 3043690371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2008 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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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 | 163WS0200X | 57283 | WV | N | Nursing Service Providers | Registered Nurse | School | 363LF0000X | 104680 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 9702069000 | 05 | WV | MEDICAID |