Healthcare Provider Details

I. General information

NPI: 1912076803
Provider Name (Legal Business Name): JENNIFER APRIL CIVIELLO CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER APRIL GLIDDEN

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 UPPER PLAIN
BRADFORD VT
05033
US

IV. Provider business mailing address

37 PARKHURST ST APT 1
LEBANON NH
03766
US

V. Phone/Fax

Practice location:
  • Phone: 802-222-4722
  • Fax: 802-222-4709
Mailing address:
  • Phone: 603-448-3016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1010031684
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: