Healthcare Provider Details

I. General information

NPI: 1356830756
Provider Name (Legal Business Name): BUCILLA HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 MCANDREWS RD W
BURNSVILLE MN MN
55337
US

IV. Provider business mailing address

1500 MCANDREWS RD W
BURNSVILLE MN MN
55337
US

V. Phone/Fax

Practice location:
  • Phone: 952-892-9393
  • Fax: 952-892-9395
Mailing address:
  • Phone: 952-892-9393
  • Fax: 952-892-9395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR156407-9
License Number StateMN

VIII. Authorized Official

Name: DR. PENNIE ELIZABETH BUCILLA
Title or Position: OWNER
Credential: APRN CNP
Phone: 952-892-9393