Provider Demographics
NPI:1477985695
Name:CICCARELLO, LYNDSEY LEIGH (MS)
Entity Type:Individual
Prefix:
First Name:LYNDSEY
Middle Name:LEIGH
Last Name:CICCARELLO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:LYNDSEY
Other - Middle Name:
Other - Last Name:CAVANAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:130 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-2106
Mailing Address - Country:US
Mailing Address - Phone:631-664-3351
Mailing Address - Fax:
Practice Address - Street 1:130 RIVIERA DR
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-2106
Practice Address - Country:US
Practice Address - Phone:631-664-3351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1107875174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist