Provider Demographics
NPI:1093737488
Name:TRICOMI, JACQUELINE M (CNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:TRICOMI
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:M
Other - Last Name:KERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2783-NP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000374507OtherANTHEM
OH363693OtherWELLCARE
OH000000526068OtherANTHEM
OH7423723OtherAETNA
OH745927OtherBUCKEYE
OH000000221188OtherUNISON
OH2348598Medicaid
OH745927OtherBUCKEYE
OH000000526068OtherANTHEM
OHKENP11512Medicare PIN