Healthcare Provider Details

I. General information

NPI: 1932695293
Provider Name (Legal Business Name): NICOLE CUCCURULLO MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 HOFSTRA UNIVERSITY
HEMPSTEAD NY
11549-2300
US

IV. Provider business mailing address

7 GORHAM LN
SMITHTOWN NY
11787-4701
US

V. Phone/Fax

Practice location:
  • Phone: 516-463-6085
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number002396
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: