Provider Demographics
NPI:1497741680
Name:SISKIND, JILL ROBIN (APRN)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ROBIN
Last Name:SISKIND
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-4051
Mailing Address - Country:US
Mailing Address - Phone:508-765-9771
Mailing Address - Fax:508-909-7735
Practice Address - Street 1:100 SOUTH ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-4051
Practice Address - Country:US
Practice Address - Phone:508-765-9771
Practice Address - Fax:508-909-7735
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE37913163W00000X
CT001917363L00000X
MARN134682363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004190188Medicaid
CT400001917CT01OtherANTHEM BCBS
CT191700OtherCONNECTICAR
CT191700OtherCONNECTICAR
CT004190188Medicaid
500000148Medicare ID - Type Unspecified