Provider Demographics
NPI:1053636019
Name:CIESLAK, NICOLE M (CST/CFA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:CIESLAK
Suffix:
Gender:F
Credentials:CST/CFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3239
Mailing Address - Country:US
Mailing Address - Phone:704-323-2000
Mailing Address - Fax:
Practice Address - Street 1:2001 VAIL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1219
Practice Address - Country:US
Practice Address - Phone:704-323-2248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL108145246ZS0410X
NC124768246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist