Provider Demographics
NPI:1700543998
Name:SIS, EMILYNE
Entity type:Individual
Prefix:
First Name:EMILYNE
Middle Name:
Last Name:SIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILYNE
Other - Middle Name:
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:MC COOK
Mailing Address - State:NE
Mailing Address - Zip Code:69001-0789
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 CENTER AVE
Practice Address - Street 2:
Practice Address - City:CURTIS
Practice Address - State:NE
Practice Address - Zip Code:69025-3014
Practice Address - Country:US
Practice Address - Phone:308-367-4885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4108225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist