Healthcare Provider Details

I. General information

NPI: 1053829408
Provider Name (Legal Business Name): KATHRYN CICCOLINI AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 E 102ND ST
NEW YORK NY
10029-6030
US

IV. Provider business mailing address

150 E 42ND ST FL 10
NEW YORK NY
10017-5626
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-6756
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberF431160-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: