Healthcare Provider Details

I. General information

NPI: 1841368479
Provider Name (Legal Business Name): MANDY M CICCARELLO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24420 STATE ROAD 54
LUTZ FL
33559-7303
US

IV. Provider business mailing address

24420 STATE ROAD 54
LUTZ FL
33559-7303
US

V. Phone/Fax

Practice location:
  • Phone: 813-909-1700
  • Fax: 813-909-2143
Mailing address:
  • Phone: 813-909-1700
  • Fax: 813-909-2143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9103828
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: