1154562536 NPI number — LISA A. CHICHERICCO-SLOAD CRNA

Table of content: TABATHA JO BERRY CRNA (NPI 1841509445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154562536 NPI number — LISA A. CHICHERICCO-SLOAD CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHICHERICCO-SLOAD
Provider First Name:
LISA
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SLOAD
Provider Other First Name:
LISA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1154562536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11368 SW MOUNTAIN ASH CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34987-2460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-721-5008
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1613 HARRISON PKWY
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
SUNRISE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33323-2896
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-437-2672
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  081646 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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