=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568239788
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | INDIJANA CICONA NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2023
-----------------------------------------------------
Last Update Date | 12/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 MOHAWK ST STE E
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31419-1768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-599-0067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1409 EBENEZER RD
-----------------------------------------------------
City | RINCON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31326-3734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-497-7471
-----------------------------------------------------
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 | RN250978
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------