Healthcare Provider Details

I. General information

NPI: 1871668756
Provider Name (Legal Business Name): JILL AMORET SISSON RN,NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JILL AMORET CORLEY-BANGERT RN,NNP

II. Dates (important events)

Enumeration Date: 11/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

7820 STATE ROUTE 4
WORDEN IL
62097-2042
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-4859
  • Fax:
Mailing address:
  • Phone: 618-633-2214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number093032
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: