Provider Demographics
NPI:1407637838
Name:SISISKY, ANDREW DAVID
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:DAVID
Last Name:SISISKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 NW 108TH AVE
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-1002
Mailing Address - Country:US
Mailing Address - Phone:305-710-4457
Mailing Address - Fax:
Practice Address - Street 1:621 NW 108TH AVE
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1002
Practice Address - Country:US
Practice Address - Phone:305-710-4457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11028133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist