Provider Demographics
NPI:1902126667
Name:SISCO, CHARITY CAROLINE (MS RDN CDCES)
Entity Type:Individual
Prefix:MRS
First Name:CHARITY
Middle Name:CAROLINE
Last Name:SISCO
Suffix:
Gender:F
Credentials:MS RDN CDCES
Other - Prefix:MRS
Other - First Name:CHARITY
Other - Middle Name:CAROLINE
Other - Last Name:SIMPKINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS RD CDE
Mailing Address - Street 1:6175 MOORES JCT RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:MI
Mailing Address - Zip Code:48659-9512
Mailing Address - Country:US
Mailing Address - Phone:989-362-9460
Mailing Address - Fax:989-654-3609
Practice Address - Street 1:335 E HOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661
Practice Address - Country:US
Practice Address - Phone:989-343-3260
Practice Address - Fax:989-362-7175
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-04
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered