Healthcare Provider Details

I. General information

NPI: 1629209028
Provider Name (Legal Business Name): JENNIFER LYNN CICCHIELLO MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER LYNN BEAL MSN, FNP-BC

II. Dates (important events)

Enumeration Date: 08/03/2009
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 E CLIFTY DR
MADISON IN
47250-4621
US

IV. Provider business mailing address

PO BOX 979
MADISON IN
47250-0979
US

V. Phone/Fax

Practice location:
  • Phone: 812-274-2742
  • Fax:
Mailing address:
  • Phone: 812-274-2742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6117P
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71003589A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: