Provider Demographics
NPI:1104534130
Name:SISSON, KAITLIN (CMT, NMT)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:SISSON
Suffix:
Gender:F
Credentials:CMT, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 WARREN LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5413
Mailing Address - Country:US
Mailing Address - Phone:707-206-8569
Mailing Address - Fax:
Practice Address - Street 1:7765 HEALDSBURG AVE STE 13C
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3355
Practice Address - Country:US
Practice Address - Phone:707-206-8569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA901962083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90196OtherCAMTC CERTIFICATION