Provider Demographics
NPI:1356307417
Name:CICUTTO, ELIZABETH GAIL (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GAIL
Last Name:CICUTTO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1210
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38503-1210
Mailing Address - Country:US
Mailing Address - Phone:931-520-1414
Mailing Address - Fax:931-520-1246
Practice Address - Street 1:112 N WALNUT AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2554
Practice Address - Country:US
Practice Address - Phone:931-520-1414
Practice Address - Fax:931-520-1246
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1336363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP02396Medicare UPIN
TN3664191Medicare ID - Type Unspecified