Provider Demographics
NPI:1174005227
Name:CISSERI HEALTH CARE
Entity Type:Organization
Organization Name:CISSERI HEALTH CARE
Other - Org Name:CISSERI HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRONDE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:313-932-2163
Mailing Address - Street 1:28931 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-1403
Mailing Address - Country:US
Mailing Address - Phone:313-932-2163
Mailing Address - Fax:
Practice Address - Street 1:28931 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336
Practice Address - Country:US
Practice Address - Phone:313-932-2163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251E00000X
251J00000X
MI4704240894363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE232323EMedicaid