Provider Demographics
NPI:1639265119
Name:SISCO, ELLEN S (MS RD)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:S
Last Name:SISCO
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:778 RATTLING ROAD
Mailing Address - Street 2:
Mailing Address - City:MICKLETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08056
Mailing Address - Country:US
Mailing Address - Phone:856-241-9624
Mailing Address - Fax:
Practice Address - Street 1:1601 KIRKWOOD HIGHWAY
Practice Address - Street 2:WILMINGTON VA MEDICAL CENTER
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805
Practice Address - Country:US
Practice Address - Phone:302-994-2511
Practice Address - Fax:302-633-5443
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
386353133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered