Provider Demographics
NPI:1902419856
Name:CISSON, MICAELA ANNE
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:ANNE
Last Name:CISSON
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 1:1504 PIEDMONT PARK RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-2047
Mailing Address - Country:US
Mailing Address - Phone:864-498-3238
Mailing Address - Fax:
Practice Address - Street 1:1180 DUTCH FORK RD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-8874
Practice Address - Country:US
Practice Address - Phone:803-781-7877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC42672183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist