Provider Demographics
NPI:1326184573
Name:RICCITELLO, MAUREEN (ARNP)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:RICCITELLO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 US HIGHWAY 1 S
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6351
Mailing Address - Country:US
Mailing Address - Phone:904-824-4990
Mailing Address - Fax:904-824-2226
Practice Address - Street 1:3100 US HIGHWAY 1 S
Practice Address - Street 2:SUITE 1
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6351
Practice Address - Country:US
Practice Address - Phone:904-824-4990
Practice Address - Fax:904-824-2226
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2771522367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY02LZMedicare ID - Type Unspecified