Healthcare Provider Details

I. General information

NPI: 1477591113
Provider Name (Legal Business Name): JOAN MARIE MICUCCI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 NORTH RD
POUGHKEEPSIE NY
12601-1328
US

IV. Provider business mailing address

6 SPUR WAY
POUGHKEEPSIE NY
12603-5523
US

V. Phone/Fax

Practice location:
  • Phone: 845-486-2850
  • Fax:
Mailing address:
  • Phone: 845-485-7511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number490101-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: