Provider Demographics
NPI:1679710206
Name:SISSON, TINA M
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:M
Last Name:SISSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TINA
Other - Middle Name:M
Other - Last Name:SISSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1301 S CENTURY CIR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8520
Mailing Address - Country:US
Mailing Address - Phone:907-376-3104
Mailing Address - Fax:907-373-2878
Practice Address - Street 1:1301 S CENTURY CIR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8520
Practice Address - Country:US
Practice Address - Phone:907-376-3104
Practice Address - Fax:907-373-2878
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator