Healthcare Provider Details

I. General information

NPI: 1194187575
Provider Name (Legal Business Name): RICHELLE LESLIE CISCO R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 THURBER DR
WATERLOO NY
13165-1665
US

IV. Provider business mailing address

31 THURBER DR
WATERLOO NY
13165-1665
US

V. Phone/Fax

Practice location:
  • Phone: 315-539-1975
  • Fax: 315-539-9493
Mailing address:
  • Phone: 315-539-1975
  • Fax: 315-539-9493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number22704940
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: