Provider Demographics
NPI:1669911269
Name:SISTARE, MARCELLINA (DC)
Entity type:Individual
Prefix:DR
First Name:MARCELLINA
Middle Name:
Last Name:SISTARE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 HAWTHORNE AVE
Mailing Address - Street 2:8
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2574
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:435 HAWTHORNE AVE
Practice Address - Street 2:8
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2574
Practice Address - Country:US
Practice Address - Phone:404-664-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008352111N00000X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation