Healthcare Provider Details

I. General information

NPI: 1740872134
Provider Name (Legal Business Name): SUSAN BURGESS SISK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2021
Last Update Date: 04/12/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9109 STONY POINT PARKWAY
RICHMOND VA
23235
US

IV. Provider business mailing address

4613 BROMLEY LN
RICHMOND VA
23226-1201
US

V. Phone/Fax

Practice location:
  • Phone: 804-560-8950
  • Fax:
Mailing address:
  • Phone: 804-937-2665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024179736
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: