Provider Demographics
NPI:1639934789
Name:CICERO, ETHAN (PHD, RN)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:
Last Name:CICERO
Suffix:
Gender:M
Credentials:PHD, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 MURRAY HILL RD
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-2510
Mailing Address - Country:US
Mailing Address - Phone:561-703-0594
Mailing Address - Fax:
Practice Address - Street 1:46 MURRAY HILL RD
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-2510
Practice Address - Country:US
Practice Address - Phone:561-703-0594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN10003654163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice