Provider Demographics
NPI:1932156551
Name:DI CECCO, JENNIFER T (CRNP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:T
Last Name:DI CECCO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14050 NW 14TH ST
Mailing Address - Street 2:SUITE 190
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2865
Mailing Address - Country:US
Mailing Address - Phone:800-424-3672
Mailing Address - Fax:954-377-3042
Practice Address - Street 1:604 STONE AVE
Practice Address - Street 2:
Practice Address - City:TALLADEGA
Practice Address - State:AL
Practice Address - Zip Code:35160-2217
Practice Address - Country:US
Practice Address - Phone:256-362-8111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-106494363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL891011490Medicaid