Provider Demographics
NPI:1891386868
Name:SISSELMAN, ELIZABETH ANN (RD, LDN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:SISSELMAN
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:TACKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:121 RUBICON RD
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-2850
Mailing Address - Country:US
Mailing Address - Phone:678-469-4823
Mailing Address - Fax:
Practice Address - Street 1:121 RUBICON RD
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-2850
Practice Address - Country:US
Practice Address - Phone:678-469-4823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004766133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered