Basic Information
| Provider Information | |||||||||
| NPI: | 1073952685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KICOS | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSN, RN, FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6046 WHIPPLE AVE NW | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447207616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304331200 | ||||||||
| FaxNumber: | 3304331666 | ||||||||
| Practice Location | |||||||||
| Address1: | 6046 WHIPPLE AVE NW | ||||||||
| Address2: | |||||||||
| City: | NORTH CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447207616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304331200 | ||||||||
| FaxNumber: | 3304331666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2013 | ||||||||
| LastUpdateDate: | 08/25/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN.350102-COA1 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0087459 | 05 | OH | MEDICAID |