Provider Demographics
NPI:1710054713
Name:CICCONE, KELLY M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:M
Last Name:CICCONE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:LAHEY CLINIC 41 MALL RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8886
Mailing Address - Fax:781-744-2956
Practice Address - Street 1:LAHEY CLINIC 41 MALL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8886
Practice Address - Fax:781-744-2956
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAQ60921Medicare UPIN
MAAP2571Medicare ID - Type Unspecified