1184896714 NPI number — MS. ROSE CICCARIELLO FAGAN CNP

Table of content: MS. ROSE CICCARIELLO FAGAN CNP (NPI 1184896714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184896714 NPI number — MS. ROSE CICCARIELLO FAGAN CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CICCARIELLO FAGAN
Provider First Name:
ROSE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CICCARIELLO FAGAN
Provider Other First Name:
ROSE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MN, CNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1184896714
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 750002
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTERVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45475
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-775-2552
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3640 COLONEL GLENN HWY
Provider Second Line Business Practice Location Address:
051 STUDENT UNION
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45435-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-775-2552
Provider Business Practice Location Address Fax Number:
937-775-3260
Provider Enumeration Date:
03/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  0198739-22 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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