Healthcare Provider Details

I. General information

NPI: 1720684871
Provider Name (Legal Business Name): LISA CICCOLELLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1181 FREEDOM RD
CRANBERRY TWP PA
16066-4913
US

IV. Provider business mailing address

228 PINE CREST CT
GIBSONIA PA
15044-8096
US

V. Phone/Fax

Practice location:
  • Phone: 724-742-1888
  • Fax:
Mailing address:
  • Phone: 412-304-3256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP439431
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: