1205964426 NPI number — LORI LYNN CICCONE PA

Table of content: LORI LYNN CICCONE PA (NPI 1205964426)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205964426 NPI number — LORI LYNN CICCONE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CICCONE
Provider First Name:
LORI
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205964426
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
322 E MAIN ST STE 1B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06405-3136
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
34-887-2282
Provider Business Mailing Address Fax Number:
203-204-1415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 GOOSE LN STE 203B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GUILFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06437-2492
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-932-6481
Provider Business Practice Location Address Fax Number:
39-324-0512
Provider Enumeration Date:
03/01/2007

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: 363A00000X , with the licence number:  001888 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 001888 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001888 . This is a "LIC" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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