Provider Demographics
NPI:1427005792
Name:DICIRO, SONYA D (FNP)
Entity Type:Individual
Prefix:
First Name:SONYA
Middle Name:D
Last Name:DICIRO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SONYA
Other - Middle Name:D
Other - Last Name:WOODSMALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:225 PHYSICIANS PARK
Mailing Address - Street 2:SUITE 400
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3956
Mailing Address - Country:US
Mailing Address - Phone:573-727-5500
Mailing Address - Fax:573-727-5599
Practice Address - Street 1:225 PHYSICIANS PARK
Practice Address - Street 2:SUITE 400
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3956
Practice Address - Country:US
Practice Address - Phone:573-727-5500
Practice Address - Fax:573-727-5599
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO093231363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428892707Medicaid
MO005013328Medicare PIN
MO428892707Medicaid