Provider Demographics
NPI:1891052833
Name:SISSON, HOLLY LYNN (MA, AT, ATC)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:LYNN
Last Name:SISSON
Suffix:
Gender:F
Credentials:MA, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-5426
Mailing Address - Country:US
Mailing Address - Phone:269-387-2701
Mailing Address - Fax:
Practice Address - Street 1:1903 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-5426
Practice Address - Country:US
Practice Address - Phone:269-387-2701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010010152255A2300X
FLAL31012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer