Provider Demographics
NPI:1841368479
Name:CICCARELLO, MANDY M (PA)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:M
Last Name:CICCARELLO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24420 STATE ROAD 54
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-7303
Mailing Address - Country:US
Mailing Address - Phone:813-909-1700
Mailing Address - Fax:813-909-2143
Practice Address - Street 1:24420 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-7303
Practice Address - Country:US
Practice Address - Phone:813-909-1700
Practice Address - Fax:813-909-2143
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103828363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical