Healthcare Provider Details

I. General information

NPI: 1447939053
Provider Name (Legal Business Name): JACQUELINE ANN CICCONE RN, BSN, MSN, CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE ANN WELCH RN, BSN, MSN, CLC

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13917 TRURO AVE
HAWTHORNE CA
90250-6832
US

IV. Provider business mailing address

13917 TRURO AVE
HAWTHORNE CA
90250-6832
US

V. Phone/Fax

Practice location:
  • Phone: 708-269-7637
  • Fax:
Mailing address:
  • Phone: 708-269-7637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number95091919
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: