Healthcare Provider Details

I. General information

NPI: 1760375315
Provider Name (Legal Business Name): CHRISTINA MARIE CICERO
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1063 RENSSELAER AVE
STATEN ISLAND NY
10309-2116
US

IV. Provider business mailing address

1063 RENSSELAER AVE
STATEN ISLAND NY
10309-2116
US

V. Phone/Fax

Practice location:
  • Phone: 917-518-4787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: