Healthcare Provider Details

I. General information

NPI: 1497325385
Provider Name (Legal Business Name): MICHELLE ELIZABETH CICCONE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GUTHRIE SQ
SAYRE PA
18840-1625
US

IV. Provider business mailing address

1 GUTHRIE SQ
SAYRE PA
18840-1625
US

V. Phone/Fax

Practice location:
  • Phone: 570-888-5858
  • Fax:
Mailing address:
  • Phone: 570-888-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN744094
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number734023
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number348238
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP024299
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: