Provider Demographics
NPI:1104230317
Name:KICAK, MARTHA MARY (LPN)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:MARY
Last Name:KICAK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 W GENESEE ST # 2105WEST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-1707
Mailing Address - Country:US
Mailing Address - Phone:315-468-3239
Mailing Address - Fax:315-468-2917
Practice Address - Street 1:2105 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-1656
Practice Address - Country:US
Practice Address - Phone:315-468-3239
Practice Address - Fax:315-468-2917
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY082747164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY082747OtherLPN
NY1609088871Medicaid