Healthcare Provider Details

I. General information

NPI: 1366319246
Provider Name (Legal Business Name): BLAKNEY JANE CICCOLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2025
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 HUDSON RD STE 3310
SUDBURY MA
01776-1753
US

IV. Provider business mailing address

29 HUDSON RD STE 3310
SUDBURY MA
01776-1753
US

V. Phone/Fax

Practice location:
  • Phone: 978-443-8810
  • Fax: 978-443-8839
Mailing address:
  • Phone: 978-443-8810
  • Fax: 978-443-8839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN208217
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: