Provider Demographics
NPI:1376326488
Name:SISLER, CAMERON (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:SISLER
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 YALE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63143-1412
Mailing Address - Country:US
Mailing Address - Phone:201-739-2504
Mailing Address - Fax:
Practice Address - Street 1:140 PROSPECT AVE STE M
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-6074
Practice Address - Country:US
Practice Address - Phone:201-739-2504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012028556133V00000X, 133VN1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics