Provider Demographics
NPI:1407237696
Name:FAMILY PRACTICE
Entity Type:Organization
Organization Name:FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CICCHIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:570-875-9434
Mailing Address - Street 1:601 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:PA
Mailing Address - Zip Code:17851-1803
Mailing Address - Country:US
Mailing Address - Phone:570-875-9434
Mailing Address - Fax:
Practice Address - Street 1:601 W 5TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:PA
Practice Address - Zip Code:17851-1803
Practice Address - Country:US
Practice Address - Phone:570-875-9434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-12
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363LA2200X, 364SP0809X
PATP006931C364SA2200X
PASP009839364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Multi-Specialty
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Multi-Specialty