MEDICARE: MILDRETH SISCO FNP-C, ENP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	5007057	NC

General Provider Information

NPI Number	:	1447653670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MILDRETH SISCO FNP-C, ENP-C

Provider Business Mailing Address
First Line	:	2817 ROCK MERRITT AVENUE ATTN: MANAGED CARE PLANNING
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-3424
Country	:	US
Telephone Number	:	910-907-8922
Fax Number	:	910-907-6069

Provider Business Practice Location Address
First Line	:	2817 ROCK MERRITT AVE
Second Line	:
City	:	FORT BRAGG
State	:	NC
Zip	:	28310-3424
Country	:	US
Telephone Number	:	910-907-8922
Fax Number	:	910-907-6069

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2014
Last Update Date	:	03/17/2025

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