Provider Demographics
NPI:1497776561
Name:CHIRICO, JACQUE (CRN)
Entity Type:Individual
Prefix:
First Name:JACQUE
Middle Name:
Last Name:CHIRICO
Suffix:
Gender:F
Credentials:CRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 BUSINESS HIGHWAY 231
Mailing Address - Street 2:
Mailing Address - City:BRUNDIDGE
Mailing Address - State:AL
Mailing Address - Zip Code:36010-1339
Mailing Address - Country:US
Mailing Address - Phone:334-735-0116
Mailing Address - Fax:334-735-0118
Practice Address - Street 1:664 BUSINESS HIGHWAY 231
Practice Address - Street 2:
Practice Address - City:BRUNDIDGE
Practice Address - State:AL
Practice Address - Zip Code:36010-1339
Practice Address - Country:US
Practice Address - Phone:334-735-0116
Practice Address - Fax:334-735-0118
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-061240363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051557146Medicaid
ALCG4892OtherMCARE B RAILROAD
ALCG4892OtherMCARE B RAILROAD