Provider Demographics
NPI:1295203537
Name:SISTAD, ABIGAIL GRACE
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:GRACE
Last Name:SISTAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203-3243
Mailing Address - Country:US
Mailing Address - Phone:507-259-0561
Mailing Address - Fax:
Practice Address - Street 1:520 N 7TH ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203-3243
Practice Address - Country:US
Practice Address - Phone:507-259-0561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer