Healthcare Provider Details

I. General information

NPI: 1558100214
Provider Name (Legal Business Name): AMANDA PUCCIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3391 RICHMOND AVENUE
STATEN ISLAND NY
10312
US

IV. Provider business mailing address

451 RAMONA AVE
STATEN ISLAND NY
10309-2434
US

V. Phone/Fax

Practice location:
  • Phone: 718-608-9170
  • Fax:
Mailing address:
  • Phone: 718-772-3384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number029148
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: