Healthcare Provider Details

I. General information

NPI: 1710374178
Provider Name (Legal Business Name): ANNETTE MINICUCCI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNETTE GRIFFING NP

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2791 AGOURA RD
THOUSAND OAKS CA
91361-3101
US

IV. Provider business mailing address

29500 HEATHERCLIFF RD SPC 217
MALIBU CA
90265-6217
US

V. Phone/Fax

Practice location:
  • Phone: 888-694-7287
  • Fax:
Mailing address:
  • Phone: 310-713-9179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number424458
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: