Provider Demographics
NPI:1194187575
Name:CISCO, RICHELLE LESLIE (RN)
Entity Type:Individual
Prefix:
First Name:RICHELLE
Middle Name:LESLIE
Last Name:CISCO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 THURBER DR
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165-1665
Mailing Address - Country:US
Mailing Address - Phone:315-539-1975
Mailing Address - Fax:315-539-9493
Practice Address - Street 1:31 THURBER DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1665
Practice Address - Country:US
Practice Address - Phone:315-539-1975
Practice Address - Fax:315-539-9493
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22704940163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse