MEDICARE: PRIMARY AND TRANSITIONAL CARE SERVICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner

General Provider Information

NPI Number	:	1558035352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY AND TRANSITIONAL CARE SERVICE

Provider Business Mailing Address
First Line	:	1501 11TH ST
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-3038
Country	:	US
Telephone Number	:	561-537-9028
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 11TH ST
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-3038
Country	:	US
Telephone Number	:	561-537-9028
Fax Number	:

Authorized Official
Title or Position	:	APRN
Name	:	KENOL CICERON
Credential	:	FNP
Telephone Number	:	561-537-9028

Provider Enumeration Date	:	08/04/2021
Last Update Date	:	08/04/2021

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