Healthcare Provider Details

I. General information

NPI: 1205098605
Provider Name (Legal Business Name): MARILOU L CICERO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HIGHLAND AVE COMPLIANCE MAIL CODE 2433
MADISON WI
53792-0001
US

IV. Provider business mailing address

600 HIGHLAND AVE COMPLIANCE MAIL CODE 2433
MADISON WI
53792-0001
US

V. Phone/Fax

Practice location:
  • Phone: 608-662-0817
  • Fax:
Mailing address:
  • Phone: 608-662-0817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number2848-033
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number139407030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: