Healthcare Provider Details

I. General information

NPI: 1104761386
Provider Name (Legal Business Name): ANN M SISLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1722 REVERE TRL
DE PERE WI
54115-1726
US

IV. Provider business mailing address

1722 REVERE TRL
DE PERE WI
54115-1726
US

V. Phone/Fax

Practice location:
  • Phone: 920-660-1031
  • Fax:
Mailing address:
  • Phone: 920-660-1031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1001467731
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: