Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 18942 | CA |
NPI | 1003140336 |
---|---|
Provider Name | Cecilia Iacoviello |
First Address | Ridgecrest, CA 93555-3130 |
Second Address | Ridgecrest, CA 93555-3131 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/09/2009 |
Last Update Date | 17/05/2021 |