Healthcare Provider Details

I. General information

NPI: 1366014664
Provider Name (Legal Business Name): COLLEEN PUCCINI APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 W HIGGINS RD STE 100
ROSEMONT IL
60018-3703
US

IV. Provider business mailing address

1365 SPAULDING RD
BARTLETT IL
60103-1205
US

V. Phone/Fax

Practice location:
  • Phone: 847-416-2625
  • Fax:
Mailing address:
  • Phone: 630-456-8598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number209.023490
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: