Provider Demographics
NPI:1578918207
Name:SISAK, AUDRA (QASP, BCCS)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:SISAK
Suffix:
Gender:F
Credentials:QASP, BCCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7711 156TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-7653
Mailing Address - Country:US
Mailing Address - Phone:609-312-8261
Mailing Address - Fax:
Practice Address - Street 1:7711 156TH STREET CT E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-7653
Practice Address - Country:US
Practice Address - Phone:609-312-8261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-02
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA174400000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist