Provider Demographics
NPI:1326727835
Name:CIASULLO, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:CIASULLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W M ST
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-2708
Mailing Address - Country:US
Mailing Address - Phone:484-635-6358
Mailing Address - Fax:
Practice Address - Street 1:1569 SOLANO AVENUE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CALIFORNIA
Practice Address - Zip Code:94530
Practice Address - Country:UM
Practice Address - Phone:510-230-4973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA000000000246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA371749452OtherOTHER