Provider Demographics
NPI:1184896714
Name:CICCARIELLO FAGAN, ROSE (CNP)
Entity type:Individual
Prefix:MS
First Name:ROSE
Middle Name:
Last Name:CICCARIELLO FAGAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:MS
Other - First Name:ROSE
Other - Middle Name:
Other - Last Name:CICCARIELLO FAGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MN, CNP
Mailing Address - Street 1:PO BOX 750002
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45475
Mailing Address - Country:US
Mailing Address - Phone:937-775-2552
Mailing Address - Fax:
Practice Address - Street 1:3640 COLONEL GLENN HWY
Practice Address - Street 2:051 STUDENT UNION
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45435-0001
Practice Address - Country:US
Practice Address - Phone:937-775-2552
Practice Address - Fax:937-775-3260
Is Sole Proprietor?:No
Enumeration Date:2008-03-24
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0198739-22363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner