Provider Demographics
NPI:1376122572
Name:CIESLAK, NICOLE (FNTP, CPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CIESLAK
Suffix:
Gender:F
Credentials:FNTP, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6901 E CHAUNCEY LN APT 2183
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-5130
Mailing Address - Country:US
Mailing Address - Phone:412-287-3259
Mailing Address - Fax:
Practice Address - Street 1:6901 E CHAUNCEY LN APT 2183
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054-5130
Practice Address - Country:US
Practice Address - Phone:412-287-3259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date: