Provider Demographics
NPI:1356674741
Name:ZICARELLI, MARY KATHRYN REEP
Entity Type:Individual
Prefix:MRS
First Name:MARY KATHRYN
Middle Name:REEP
Last Name:ZICARELLI
Suffix:
Gender:F
Credentials:
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 349
Mailing Address - Street 2:34011 HWY 280 EAST
Mailing Address - City:CHILDERSBURG
Mailing Address - State:AL
Mailing Address - Zip Code:35044-0349
Mailing Address - Country:US
Mailing Address - Phone:256-378-3313
Mailing Address - Fax:256-378-3315
Practice Address - Street 1:34011 US HIGHWAY 280
Practice Address - Street 2:
Practice Address - City:CHILDERSBURG
Practice Address - State:AL
Practice Address - Zip Code:35044-2128
Practice Address - Country:US
Practice Address - Phone:256-378-3313
Practice Address - Fax:256-378-3315
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-036663163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1021507842OtherMEDICARE PTAN
AL125065Medicaid