Healthcare Provider Details

I. General information

NPI: 1720430085
Provider Name (Legal Business Name): ELISA PUCCIO MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 W 35TH ST FL 16
NEW YORK NY
10001-1907
US

IV. Provider business mailing address

5926 MENAHAN ST
RIDGEWOOD NY
11385-2045
US

V. Phone/Fax

Practice location:
  • Phone: 718-728-8476
  • Fax:
Mailing address:
  • Phone: 917-916-2268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1278795
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: