Provider Demographics
NPI:1558805267
Name:CICCONE, BRIANNA (PHYSICAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:CICCONE
Suffix:
Gender:F
Credentials:PHYSICAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 COLUMBUS SQ UNIT 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5911
Mailing Address - Country:US
Mailing Address - Phone:845-988-6502
Mailing Address - Fax:
Practice Address - Street 1:920 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-3447
Practice Address - Country:US
Practice Address - Phone:845-988-6502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6018363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant