Healthcare Provider Details

I. General information

NPI: 1407237696
Provider Name (Legal Business Name): FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 08/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 5TH ST
MOUNT CARMEL PA
17851-1803
US

IV. Provider business mailing address

601 W 5TH ST
MOUNT CARMEL PA
17851-1803
US

V. Phone/Fax

Practice location:
  • Phone: 570-875-9434
  • Fax:
Mailing address:
  • Phone: 570-875-9434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberTP006931C
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License NumberSP009839
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: JOAN M CICCHIELLO
Title or Position: EXECUTIVE
Credential: NP
Phone: 570-875-9434