Basic Information
| Provider Information | |||||||||
| NPI: | 1932105145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PICKETT | ||||||||
| FirstName: | CICELY | ||||||||
| MiddleName: | MONIQUE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 PUMPHREY FARM DR | ||||||||
| Address2: | |||||||||
| City: | MILLERSVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211081485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102995101 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1701 TWIN SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | HALETHORPE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212273553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007777904 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | D61821 | MD | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 376751500 | 05 | MD | MEDICAID | 0038 | 01 | MD | CAREFIRST-DC | OTHER | 642258-02 | 01 | MD | CAREFIRST-MD | OTHER |