MEDICARE: MS. SHAVONDA SISSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1770984882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHAVONDA SISSON

Provider Business Mailing Address
First Line	:	2024 W CLARKE ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53206-1514
Country	:	US
Telephone Number	:	414-324-9134
Fax Number	:

Provider Business Practice Location Address
First Line	:	2024 W CLARKE ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53206-1514
Country	:	US
Telephone Number	:	414-324-9134
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2014
Last Update Date	:	09/08/2014

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