Provider Demographics
NPI:1366081887
Name:KISSEADOO, MAVIS (PMHNP)
Entity type:Individual
Prefix:
First Name:MAVIS
Middle Name:
Last Name:KISSEADOO
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10208 HICKORY RIDGE RD APT 302
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-4688
Mailing Address - Country:US
Mailing Address - Phone:667-200-6144
Mailing Address - Fax:
Practice Address - Street 1:10208 HICKORY RIDGE RD APT 302
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-4688
Practice Address - Country:US
Practice Address - Phone:667-200-6144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-01
Last Update Date:2020-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR205356363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health