Provider Demographics
NPI:1497348619
Name:SISSON, SANDRA LYNN (PT)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
Last Name:SISSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9130 GREENLEAF CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-8310
Mailing Address - Country:US
Mailing Address - Phone:239-940-5959
Mailing Address - Fax:
Practice Address - Street 1:2525 FIRST ST
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-2465
Practice Address - Country:US
Practice Address - Phone:239-940-5959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0011868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist