Provider Demographics
NPI:1285758110
Name:CICCARELLI, DIANE (EDD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:CICCARELLI
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 SE PARAKEET LN
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-3421
Mailing Address - Country:US
Mailing Address - Phone:772-708-4883
Mailing Address - Fax:772-210-6834
Practice Address - Street 1:1225 SE PARAKEET LN
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3421
Practice Address - Country:US
Practice Address - Phone:772-708-4883
Practice Address - Fax:772-210-6834
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL681856196171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL681856196Medicaid
FL681856198Medicaid
FL681856168Medicaid
FL681856168Medicaid