Provider Demographics
NPI:1427425719
Name:SISK, BONNIE DURRETT (HAS)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:DURRETT
Last Name:SISK
Suffix:
Gender:F
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 W SOUTH ST # 200
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-2265
Mailing Address - Country:US
Mailing Address - Phone:662-469-3277
Mailing Address - Fax:662-912-9918
Practice Address - Street 1:165 W SOUTH ST # 200
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-2265
Practice Address - Country:US
Practice Address - Phone:662-469-3277
Practice Address - Fax:662-912-9918
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSHA0621237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSHA0621OtherMS DEPT OF HEALTH