Provider Demographics
NPI:1457792202
Name:CISSELL, MARLA CLAIRE
Entity type:Individual
Prefix:MRS
First Name:MARLA
Middle Name:CLAIRE
Last Name:CISSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MARLA
Other - Middle Name:CLAIRE
Other - Last Name:LACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:315 E UNION AVE
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:AR
Mailing Address - Zip Code:72370-3235
Mailing Address - Country:US
Mailing Address - Phone:870-563-1331
Mailing Address - Fax:870-563-1211
Practice Address - Street 1:315 E UNION AVE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370-3235
Practice Address - Country:US
Practice Address - Phone:870-563-1331
Practice Address - Fax:870-563-1211
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR196878795Medicaid