Healthcare Provider Details

I. General information

NPI: 1700109006
Provider Name (Legal Business Name): MARY BURKE TRICOLLI RN, L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2010
Last Update Date: 03/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 BROADWAY SUITE 404
NEW YORK NY
10003-1210
US

IV. Provider business mailing address

1 MORTON SQ #3CE
NEW YORK NY
10014-7800
US

V. Phone/Fax

Practice location:
  • Phone: 617-877-1004
  • Fax:
Mailing address:
  • Phone: 617-877-1004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number623668-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number004240-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: