Healthcare Provider Details

I. General information

NPI: 1497741680
Provider Name (Legal Business Name): JILL ROBIN SISKIND APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

IV. Provider business mailing address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-9771
  • Fax: 508-909-7735
Mailing address:
  • Phone: 508-765-9771
  • Fax: 508-909-7735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberE37913
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number001917
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN134682
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: