Healthcare Provider Details

I. General information

NPI: 1003286147
Provider Name (Legal Business Name): MARISA GARGIULO CIAMPI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1632 VICTORY BLVD
STATEN ISLAND NY
10314-3504
US

IV. Provider business mailing address

370 LITTLE CLOVE RD
STATEN ISLAND NY
10301-4138
US

V. Phone/Fax

Practice location:
  • Phone: 718-448-9650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number831179373
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: