Healthcare Provider Details

I. General information

NPI: 1376637892
Provider Name (Legal Business Name): DONNA K CISSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 NORTH BOULEVARD
TOCCOA GA
30577
US

IV. Provider business mailing address

6762 HANCOCK DR
TOCCOA GA
30577
US

V. Phone/Fax

Practice location:
  • Phone: 706-282-4507
  • Fax: 706-282-4511
Mailing address:
  • Phone: 706-282-4504
  • Fax: 706-282-4511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN101513
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: