Healthcare Provider Details

I. General information

NPI: 1932105145
Provider Name (Legal Business Name): CICELY MONIQUE PICKETT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 06/17/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 TWIN SPRINGS RD
HALETHORPE MD
21227-3553
US

IV. Provider business mailing address

701 PUMPHREY FARM DR
MILLERSVILLE MD
21108-1485
US

V. Phone/Fax

Practice location:
  • Phone: 800-777-7904
  • Fax:
Mailing address:
  • Phone: 410-299-5101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD61821
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: