Provider Demographics
NPI:1164550026
Name:STACY SISSON
Entity Type:Organization
Organization Name:STACY SISSON
Other - Org Name:PROTEC LABS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SISSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:314-960-0957
Mailing Address - Street 1:5608 CLIFF CAVE CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-4368
Mailing Address - Country:US
Mailing Address - Phone:314-960-0957
Mailing Address - Fax:314-846-1161
Practice Address - Street 1:5608 CLIFF CAVE CROSSING DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-4368
Practice Address - Country:US
Practice Address - Phone:314-960-0957
Practice Address - Fax:314-846-1161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO143216374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374700000XNursing Service Related ProvidersTechnicianGroup - Single Specialty