Healthcare Provider Details

I. General information

NPI: 1043696404
Provider Name (Legal Business Name): NICHOLAS PUCILLO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2015
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4611 OUTER LOOP
LOUISVILLE KY
40219-3970
US

IV. Provider business mailing address

800 CRESCENT CENTRE DR STE 300
FRANKLIN TN
37067-7285
US

V. Phone/Fax

Practice location:
  • Phone: 502-625-6233
  • Fax: 502-625-6234
Mailing address:
  • Phone: 616-373-1350
  • Fax: 615-221-9054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number006671
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: