Provider Demographics
NPI:1942626486
Name:GERALD, SISHANA JANELLE (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:MRS
First Name:SISHANA
Middle Name:JANELLE
Last Name:GERALD
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4714 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-4302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4045 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3454
Practice Address - Country:US
Practice Address - Phone:520-981-7380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-07
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ105020321744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
1744P3200XOtherNON SURGICAL HAIR REPLACEMENT