Healthcare Provider Details

I. General information

NPI: 1356674741
Provider Name (Legal Business Name): MRS. MARY KATHRYN REEP ZICARELLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34011 US HIGHWAY 280
CHILDERSBURG AL
35044-2128
US

IV. Provider business mailing address

PO BOX 349 34011 HWY 280 EAST
CHILDERSBURG AL
35044-0349
US

V. Phone/Fax

Practice location:
  • Phone: 256-378-3313
  • Fax: 256-378-3315
Mailing address:
  • Phone: 256-378-3313
  • Fax: 256-378-3315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-036663
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-036663
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: