Provider Demographics
NPI:1215635735
Name:GICHABA, CECILIA B
Entity type:Individual
Prefix:
First Name:CECILIA
Middle Name:B
Last Name:GICHABA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8346 WESTCLIFFE DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-6743
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:504 GRAND VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-5883
Practice Address - Country:US
Practice Address - Phone:765-516-6275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71013613A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71013613AOtherAPRN PRESCRIPTIVE AUTHORITY