Provider Demographics
NPI:1205310661
Name:SISTO-WATSON, LORAINE GRACE
Entity type:Individual
Prefix:MRS
First Name:LORAINE
Middle Name:GRACE
Last Name:SISTO-WATSON
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 1:2019 E OKMULGEE AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-5841
Mailing Address - Country:US
Mailing Address - Phone:405-838-0999
Mailing Address - Fax:
Practice Address - Street 1:2019 E OKMULGEE AVE
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-5841
Practice Address - Country:US
Practice Address - Phone:405-838-0999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK171M00000XMedicaid