Healthcare Provider Details

I. General information

NPI: 1053610097
Provider Name (Legal Business Name): LISA WONDERS CICCOCIOPPI MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 9TH AVE N
JACKSONVILLE FL
32250-5745
US

IV. Provider business mailing address

416 9TH AVE N
JACKSONVILLE FL
32250-5745
US

V. Phone/Fax

Practice location:
  • Phone: 717-418-2888
  • Fax:
Mailing address:
  • Phone: 717-418-2888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: