Healthcare Provider Details

I. General information

NPI: 1538400825
Provider Name (Legal Business Name): ELIZABETH CICCANTELLI LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 WILDER LOOP NE
RIO RANCHO NM
87144-1441
US

IV. Provider business mailing address

2705 WILDER LOOP NE
RIO RANCHO NM
87144-1441
US

V. Phone/Fax

Practice location:
  • Phone: 505-264-8121
  • Fax:
Mailing address:
  • Phone: 505-264-8121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL19310
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: