Provider Demographics
NPI:1891045282
Name:CISSOM, ANGELA MARIE (AUD)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MARIE
Last Name:CISSOM
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 POPLAR AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-4426
Mailing Address - Country:US
Mailing Address - Phone:901-762-0125
Mailing Address - Fax:901-818-3001
Practice Address - Street 1:4646 POPLAR AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4426
Practice Address - Country:US
Practice Address - Phone:901-762-0125
Practice Address - Fax:901-818-3001
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01274231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1726OtherSTATE OF TENNESSEE DEPARTMENT OF HEALTH DIVISION OF HEALTH RELATED BOARDS