Healthcare Provider Details

I. General information

NPI: 1407899644
Provider Name (Legal Business Name): CHRISTINE M CICCO-BROWN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11715 RANGELAND PKWY
BRADENTON FL
34211-9529
US

IV. Provider business mailing address

11715 RANGELAND PKWY
BRADENTON FL
34211-9529
US

V. Phone/Fax

Practice location:
  • Phone: 941-538-0018
  • Fax: 941-538-0019
Mailing address:
  • Phone: 941-538-0018
  • Fax: 941-538-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberOS10183
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: