Healthcare Provider Details

I. General information

NPI: 1497594279
Provider Name (Legal Business Name): GENNA CICCARELLI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5309 IDLEWILD RD N
MINT HILL NC
28227-3962
US

IV. Provider business mailing address

1626 ROWEMONT DR
DURHAM NC
27705-6914
US

V. Phone/Fax

Practice location:
  • Phone: 704-573-9777
  • Fax:
Mailing address:
  • Phone: 484-425-7909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number320691
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: