Healthcare Provider Details

I. General information

NPI: 1033173539
Provider Name (Legal Business Name): JACQUELINE GANNUSCIO ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 IRVING ST NW RM. 1E 301A
WASHINGTON DC
20422-0001
US

IV. Provider business mailing address

7712 GOODFELLOW WAY
DERWOOD MD
20855-2259
US

V. Phone/Fax

Practice location:
  • Phone: 202-745-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number045488-23-12
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: