Provider Demographics
NPI:1043493877
Name:SISCO, KAREN KAY (PT)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:KAY
Last Name:SISCO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11315 MCCORMICK RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38002-9512
Mailing Address - Country:US
Mailing Address - Phone:901-292-5313
Mailing Address - Fax:901-867-3340
Practice Address - Street 1:11315 MCCORMICK RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38002-9512
Practice Address - Country:US
Practice Address - Phone:901-292-5313
Practice Address - Fax:901-867-3340
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-15
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT00000049032251P0200X
MSPT42922251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08602897Medicaid