Provider Demographics
NPI:1053140103
Name:RISINGER, KENNETH JOHN (PMHNP)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name:RISINGER
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 E GOVERNMENT ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-3255
Mailing Address - Country:US
Mailing Address - Phone:903-824-8880
Mailing Address - Fax:
Practice Address - Street 1:411 E GOVERNMENT ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-3255
Practice Address - Country:US
Practice Address - Phone:903-824-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906843363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health