Healthcare Provider Details

I. General information

NPI: 1366846784
Provider Name (Legal Business Name): WILLIAM R PROCACCINI RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2014
Last Update Date: 10/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 6TH AVE S
ST PETERSBURG FL
33701-4634
US

IV. Provider business mailing address

501 6TH AVE S
ST PETERSBURG FL
33701-4634
US

V. Phone/Fax

Practice location:
  • Phone: 727-767-3578
  • Fax: 727-767-4249
Mailing address:
  • Phone: 727-767-3578
  • Fax: 727-767-4249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberND5446
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: