Healthcare Provider Details

I. General information

NPI: 1255819348
Provider Name (Legal Business Name): JORDAN FICOCELLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 HOWARD AVE # 2
NEW HAVEN CT
06519
US

IV. Provider business mailing address

254 MICA HILL RD
DURHAM CT
06422-3311
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-2571
  • Fax:
Mailing address:
  • Phone: 203-627-4950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12.007724
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number12.007724
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: