Provider Demographics
NPI:1912076803
Name:CIVIELLO, JENNIFER APRIL (CPNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:APRIL
Last Name:CIVIELLO
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:APRIL
Other - Last Name:GLIDDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:37 PARKHURST ST
Mailing Address - Street 2:APT 1
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766
Mailing Address - Country:US
Mailing Address - Phone:603-448-3016
Mailing Address - Fax:
Practice Address - Street 1:331 UPPER PLAIN
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:VT
Practice Address - Zip Code:05033
Practice Address - Country:US
Practice Address - Phone:802-222-4722
Practice Address - Fax:802-222-4709
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010031684363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30344253Medicaid
VT1012431Medicaid