Provider Demographics
NPI:1679243281
Name:SICCA, CRISTALROSE
Entity Type:Individual
Prefix:
First Name:CRISTALROSE
Middle Name:
Last Name:SICCA
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 1:7052 HYLAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10307-1937
Mailing Address - Country:US
Mailing Address - Phone:347-255-3920
Mailing Address - Fax:
Practice Address - Street 1:7052 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10307-1937
Practice Address - Country:US
Practice Address - Phone:347-255-3920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist