Provider Demographics
NPI:1932105145
Name:PICKETT, CICELY MONIQUE (MD)
Entity Type:Individual
Prefix:DR
First Name:CICELY
Middle Name:MONIQUE
Last Name:PICKETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PUMPHREY FARM DR
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1485
Mailing Address - Country:US
Mailing Address - Phone:410-299-5101
Mailing Address - Fax:
Practice Address - Street 1:1701 TWIN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:HALETHORPE
Practice Address - State:MD
Practice Address - Zip Code:21227-3553
Practice Address - Country:US
Practice Address - Phone:800-777-7904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD61821207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD376751500Medicaid
MD0038OtherCAREFIRST-DC
MD642258-02OtherCAREFIRST-MD
MD539P081HMedicare PIN
MD376751500Medicaid