Provider Demographics
NPI:1528582723
Name:KICONCO, SHEILLA
Entity Type:Individual
Prefix:DR
First Name:SHEILLA
Middle Name:
Last Name:KICONCO
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 1:1749 GRAND CONCOURSE APT 9G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453
Mailing Address - Country:US
Mailing Address - Phone:914-258-1361
Mailing Address - Fax:
Practice Address - Street 1:3015 3RD AVE SE STE 104
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-5539
Practice Address - Country:US
Practice Address - Phone:605-725-6700
Practice Address - Fax:605-725-6708
Is Sole Proprietor?:No
Enumeration Date:2017-07-29
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SD12075208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program