Healthcare Provider Details

I. General information

NPI: 1124658067
Provider Name (Legal Business Name): MARIANNA GRACE BETTINA PUCILLO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2020
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10121 PINE AVE
TRUCKEE CA
96161-4835
US

IV. Provider business mailing address

PO BOX 77
TAHOE CITY CA
96145-0077
US

V. Phone/Fax

Practice location:
  • Phone: 530-550-7206
  • Fax:
Mailing address:
  • Phone: 781-454-9342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95013728
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: