Provider Demographics
NPI:1205430394
Name:SISLO, KATHLEEN (RDN, CD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SISLO
Suffix:
Gender:F
Credentials:RDN, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 WESTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROTHSCHILD
Mailing Address - State:WI
Mailing Address - Zip Code:54474-1102
Mailing Address - Country:US
Mailing Address - Phone:920-347-9833
Mailing Address - Fax:
Practice Address - Street 1:112 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2710
Practice Address - Country:US
Practice Address - Phone:715-623-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86150618133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal