=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205657632
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISTY CICHORACKI FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2024
-----------------------------------------------------
Last Update Date | 10/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7542 PIERCE ST
-----------------------------------------------------
City | ARVADA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80003-2815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-517-4478
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7542 PIERCE ST
-----------------------------------------------------
City | ARVADA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80003-2815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-517-4478
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 1000050-NP
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------