Provider Demographics
NPI:1528339785
Name:SISCO, PATSY ANN
Entity type:Individual
Prefix:MRS
First Name:PATSY
Middle Name:ANN
Last Name:SISCO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:PATSY
Other - Middle Name:WILBURN
Other - Last Name:WILKERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:309 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RED BOILING SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37150-2149
Mailing Address - Country:US
Mailing Address - Phone:615-699-2238
Mailing Address - Fax:
Practice Address - Street 1:309 MAIN ST
Practice Address - Street 2:
Practice Address - City:RED BOILING SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37150-2149
Practice Address - Country:US
Practice Address - Phone:615-699-2238
Practice Address - Fax:615-699-2235
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN199224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant