Provider Demographics
NPI:1790382521
Name:SISK, SHASTA RACHELLE
Entity Type:Individual
Prefix:
First Name:SHASTA
Middle Name:RACHELLE
Last Name:SISK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 SPRUCE CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT GAY
Mailing Address - State:WV
Mailing Address - Zip Code:25514
Mailing Address - Country:US
Mailing Address - Phone:304-648-8427
Mailing Address - Fax:
Practice Address - Street 1:609 SPRUCE CREEK ROAD
Practice Address - Street 2:
Practice Address - City:FORT GAY
Practice Address - State:WV
Practice Address - Zip Code:25514
Practice Address - Country:US
Practice Address - Phone:304-648-8427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant