Provider Demographics
NPI:1124138706
Name:MICCICHE, JANE HELENA (APRN)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:HELENA
Last Name:MICCICHE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:FRANCONIA
Mailing Address - State:NH
Mailing Address - Zip Code:03580-5021
Mailing Address - Country:US
Mailing Address - Phone:603-823-8554
Mailing Address - Fax:603-823-8554
Practice Address - Street 1:97 SHERMAN DR
Practice Address - Street 2:SUITE 1
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9280
Practice Address - Country:US
Practice Address - Phone:802-748-5131
Practice Address - Fax:802-748-4237
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010015859363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1005217Medicaid
NH30008266Medicaid
NH30008266Medicaid
VTS27461Medicare UPIN