Healthcare Provider Details

I. General information

NPI: 1417094657
Provider Name (Legal Business Name): SHELLEY CISSELL PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E MATTHEWS AVE STE 102
JONESBORO AR
72401-3101
US

IV. Provider business mailing address

3115 BOWDEN DR
JONESBORO AR
72404-6867
US

V. Phone/Fax

Practice location:
  • Phone: 870-972-4563
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 1867
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: