Provider Demographics
NPI:1629209028
Name:CICCHIELLO, JENNIFER LYNN (MSN, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:CICCHIELLO
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:BEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, FNP-BC
Mailing Address - Street 1:PO BOX 979
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-0979
Mailing Address - Country:US
Mailing Address - Phone:812-274-2742
Mailing Address - Fax:
Practice Address - Street 1:311 E CLIFTY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-4621
Practice Address - Country:US
Practice Address - Phone:812-274-2742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6117P363LF0000X
IN71003589A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily