Provider Demographics
NPI:1316114655
Name:NICOSIA, CHANDA LEA (CSFA/LSA)
Entity type:Individual
Prefix:MRS
First Name:CHANDA
Middle Name:LEA
Last Name:NICOSIA
Suffix:
Gender:F
Credentials:CSFA/LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13674 ARIZONA DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75707-6806
Mailing Address - Country:US
Mailing Address - Phone:903-216-3561
Mailing Address - Fax:903-566-6816
Practice Address - Street 1:13674 ARIZONA DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75707-6806
Practice Address - Country:US
Practice Address - Phone:903-216-3561
Practice Address - Fax:903-566-6816
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
TXSA00471246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant