Provider Demographics
NPI:1245705490
Name:DICICCO, DANIELLE (FNP-C)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:DICICCO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10240 CONTINENTAL DR
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3109
Mailing Address - Country:US
Mailing Address - Phone:313-299-1977
Mailing Address - Fax:
Practice Address - Street 1:3902 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48125-2545
Practice Address - Country:US
Practice Address - Phone:313-562-1985
Practice Address - Fax:313-562-0380
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-03
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704273013363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily