Healthcare Provider Details

I. General information

NPI: 1164550026
Provider Name (Legal Business Name): STACY SISSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5608 CLIFF CAVE CROSSING DR
SAINT LOUIS MO
63129-4368
US

IV. Provider business mailing address

5608 CLIFF CAVE CROSSING DR
SAINT LOUIS MO
63129-4368
US

V. Phone/Fax

Practice location:
  • Phone: 314-960-0957
  • Fax: 314-846-1161
Mailing address:
  • Phone: 314-960-0957
  • Fax: 314-846-1161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number143216
License Number StateMO

VIII. Authorized Official

Name: MRS. STACY J SISSON
Title or Position: OWNER
Credential: R.N.
Phone: 314-960-0957