Healthcare Provider Details

I. General information

NPI: 1568239788
Provider Name (Legal Business Name): INDIJANA CICONA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

900 MOHAWK ST STE E
SAVANNAH GA
31419-1768
US

IV. Provider business mailing address

1409 EBENEZER RD
RINCON GA
31326-3734
US

V. Phone/Fax

Practice location:
  • Phone: 800-599-0067
  • Fax:
Mailing address:
  • Phone: 262-497-7471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN250978
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: