Healthcare Provider Details

I. General information

NPI: 1881264992
Provider Name (Legal Business Name): MICHAEL C CICCARONE DNP, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 TAMIAMI TRL S STE 108
VENICE FL
34285-4133
US

IV. Provider business mailing address

1101 TAMIAMI TRL S STE 108
VENICE FL
34285-4133
US

V. Phone/Fax

Practice location:
  • Phone: 941-488-2332
  • Fax:
Mailing address:
  • Phone: 941-488-2332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11017354
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: