Provider Demographics
NPI:1306309737
Name:SISSOM, DONLEY (LAC, DIPAC)
Entity type:Individual
Prefix:
First Name:DONLEY
Middle Name:
Last Name:SISSOM
Suffix:
Gender:M
Credentials:LAC, DIPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 CASCADIA LN
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4801
Mailing Address - Country:US
Mailing Address - Phone:360-306-9631
Mailing Address - Fax:
Practice Address - Street 1:1116 KEY ST STE 109
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5251
Practice Address - Country:US
Practice Address - Phone:360-306-9631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAACUP.AC.60948175171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist