Healthcare Provider Details

I. General information

NPI: 1023172699
Provider Name (Legal Business Name): THERESA MARIE CIROCCO N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD RM E235
DETROIT MI
48202-2608
US

IV. Provider business mailing address

11919 CHASE BLVD
LIVONIA MI
48150-5039
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2417
  • Fax: 313-916-8416
Mailing address:
  • Phone: 734-953-2665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704168297
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: