Provider Demographics
NPI:1558693986
Name:DECICCO-JONES, MONIQUE DEMETREAL (RN,MSN,MHA, FNP)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:DEMETREAL
Last Name:DECICCO-JONES
Suffix:
Gender:F
Credentials:RN,MSN,MHA, FNP
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:DEMETREAL
Other - Last Name:DECICCO-JONES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:180 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-1829
Mailing Address - Country:US
Mailing Address - Phone:845-292-9114
Mailing Address - Fax:
Practice Address - Street 1:180 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-1829
Practice Address - Country:US
Practice Address - Phone:845-292-9114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-10
Last Update Date:2013-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY510240-1163W00000X, 163WC0400X, 163WD0400X, 163WG0000X, 163WN1003X
NY33 338064363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WN1003XNursing Service ProvidersRegistered NurseNutrition Support