Healthcare Provider Details

I. General information

NPI: 1801368626
Provider Name (Legal Business Name): ASHLEY BETH CICCARELLO FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14550 SOLEDAD CANYON RD
CANYON COUNTRY CA
91387-2200
US

IV. Provider business mailing address

PO BOX 9602
MISSION HILLS CA
91346-9602
US

V. Phone/Fax

Practice location:
  • Phone: 661-250-5200
  • Fax:
Mailing address:
  • Phone: 818-837-5559
  • Fax: 818-792-4793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95010703
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: