Healthcare Provider Details

I. General information

NPI: 1588200877
Provider Name (Legal Business Name): LAURA KEEL SISSON AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

2830 VICTORY PKWY
CINCINNATI OH
45206-1785
US

V. Phone/Fax

Practice location:
  • Phone: 513-475-8282
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0029160
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1-175582
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: