Provider Demographics
NPI:1821691353
Name:SICULIANO, JENNIFER
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:SICULIANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5510 KINGSLEY MNR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6113
Mailing Address - Country:US
Mailing Address - Phone:404-798-1177
Mailing Address - Fax:
Practice Address - Street 1:3095 OLD ATLANTA RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-2737
Practice Address - Country:US
Practice Address - Phone:770-844-5686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH018827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist