Healthcare Provider Details

I. General information

NPI: 1346523354
Provider Name (Legal Business Name): JENNIFER R. CICCONE PHARMD, IMMUNIZER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13700 E COLONIAL DR
ORLANDO FL
32826-4962
US

IV. Provider business mailing address

13700 E COLONIAL DR
ORLANDO FL
32826-4962
US

V. Phone/Fax

Practice location:
  • Phone: 407-382-9291
  • Fax: 407-282-5417
Mailing address:
  • Phone: 407-382-9291
  • Fax: 407-282-5417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS39290
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: