Healthcare Provider Details

I. General information

NPI: 1568076651
Provider Name (Legal Business Name): MISS KELLY MICKEY SISOWATH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2020
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date: 07/22/2024
Reactivation Date: 08/23/2024

III. Provider practice location address

90 W ASHLAN AVE STE 101
CLOVIS CA
93612-5627
US

IV. Provider business mailing address

90 W ASHLAN AVE STE 101
CLOVIS CA
93612-5627
US

V. Phone/Fax

Practice location:
  • Phone: 559-326-5696
  • Fax: 559-326-5699
Mailing address:
  • Phone: 559-326-5696
  • Fax: 559-326-5699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: