Provider Demographics
NPI:1306118856
Name:HISSIN, CAROL LYNN
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:LYNN
Last Name:HISSIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 STATE ROUTE 369 LOT 49
Mailing Address - Street 2:
Mailing Address - City:PORT CRANE
Mailing Address - State:NY
Mailing Address - Zip Code:13833-1033
Mailing Address - Country:US
Mailing Address - Phone:697-648-9391
Mailing Address - Fax:
Practice Address - Street 1:761 STATE ROUTE 369 LOT 49
Practice Address - Street 2:
Practice Address - City:PORT CRANE
Practice Address - State:NY
Practice Address - Zip Code:13833-1033
Practice Address - Country:US
Practice Address - Phone:697-648-9391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10275094164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse