Healthcare Provider Details

I. General information

NPI: 1679545818
Provider Name (Legal Business Name): ANNIE MAPANAO CICHOCKI REGISTERED DIETIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: ANNIE LALIN MAPANAO

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 VINCENT ST
PETERSON AIR FORCE BASE CO
80914-1540
US

IV. Provider business mailing address

559 VINCENT ST 21ST MEDICAL GROUP SGHQ
PETERSON AFB CO
80914-1540
US

V. Phone/Fax

Practice location:
  • Phone: 719-556-1060
  • Fax: 719-556-9677
Mailing address:
  • Phone: 719-556-1060
  • Fax: 719-556-9677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDN0000000675
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: