Healthcare Provider Details

I. General information

NPI: 1194029199
Provider Name (Legal Business Name): CAROL ANN DICESARE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2011
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 LATTA RD
ROCHESTER NY
14612-4022
US

IV. Provider business mailing address

1200 LATTA RD
ROCHESTER NY
14612-4022
US

V. Phone/Fax

Practice location:
  • Phone: 585-966-3990
  • Fax: 585-581-8109
Mailing address:
  • Phone: 585-966-3990
  • Fax: 585-581-8109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number507867-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: