Provider Demographics
NPI:1215102603
Name:SISLEY, SAMUEL JAMES (RD LDN)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:JAMES
Last Name:SISLEY
Suffix:
Gender:M
Credentials:RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 HONOR HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-1318
Mailing Address - Country:US
Mailing Address - Phone:918-577-3735
Mailing Address - Fax:918-577-3829
Practice Address - Street 1:1011 HONOR HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-1318
Practice Address - Country:US
Practice Address - Phone:918-577-3735
Practice Address - Fax:918-577-3829
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL001797133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered