Provider Demographics
NPI:1447702535
Name:SISE, VIRGINIA CAROL (FNP-BC)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:CAROL
Last Name:SISE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 LONG DR
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-3691
Mailing Address - Country:US
Mailing Address - Phone:443-553-5102
Mailing Address - Fax:
Practice Address - Street 1:1505 E CHURCHVILLE RD
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4742
Practice Address - Country:US
Practice Address - Phone:410-420-6970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR130847363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily