Healthcare Provider Details

I. General information

NPI: 1184896714
Provider Name (Legal Business Name): ROSE CICCARIELLO FAGAN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ROSE CICCARIELLO FAGAN MN, CNP

II. Dates (important events)

Enumeration Date: 03/24/2008
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 COLONEL GLENN HWY 051 STUDENT UNION
DAYTON OH
45435-0001
US

IV. Provider business mailing address

PO BOX 750002
CENTERVILLE OH
45475
US

V. Phone/Fax

Practice location:
  • Phone: 937-775-2552
  • Fax: 937-775-3260
Mailing address:
  • Phone: 937-775-2552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0198739-22
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: