Healthcare Provider Details

I. General information

NPI: 1891045282
Provider Name (Legal Business Name): ANGELA MARIE CISSOM AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 POPLAR AVE SUITE 100
MEMPHIS TN
38117-4426
US

IV. Provider business mailing address

4646 POPLAR AVE SUITE 100
MEMPHIS TN
38117-4426
US

V. Phone/Fax

Practice location:
  • Phone: 901-762-0125
  • Fax: 901-818-3001
Mailing address:
  • Phone: 901-762-0125
  • Fax: 901-818-3001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number01274
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: