Healthcare Provider Details

I. General information

NPI: 1215422068
Provider Name (Legal Business Name): MARY CATHERINE CISCO DNP, MBA, MSN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY CATHERINE CISCO DNP, MBA, MSN, FNPC

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 N 1ST ST
LEESBURG FL
34748-5150
US

IV. Provider business mailing address

110 S WOODLAND ST
WINTER GARDEN FL
34787-3546
US

V. Phone/Fax

Practice location:
  • Phone: 407-905-8827
  • Fax: 352-360-2389
Mailing address:
  • Phone: 407-905-8827
  • Fax: 321-221-9454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9404063
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: