Provider Demographics
NPI:1689821225
Name:SANTICOLA, MARTHA DRISCOLL
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:DRISCOLL
Last Name:SANTICOLA
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 1:2101 ROUTE 214
Mailing Address - Street 2:
Mailing Address - City:LANESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12450-1209
Mailing Address - Country:US
Mailing Address - Phone:518-755-7373
Mailing Address - Fax:
Practice Address - Street 1:2101 ROUTE 214
Practice Address - Street 2:
Practice Address - City:LANESVILLE
Practice Address - State:NY
Practice Address - Zip Code:12450-1209
Practice Address - Country:US
Practice Address - Phone:518-755-7373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist