Healthcare Provider Details

I. General information

NPI: 1174044523
Provider Name (Legal Business Name): MARY CUCINELLO REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 SPARKILL AVE
TAPPAN NY
10983-2208
US

IV. Provider business mailing address

21 SPARKILL AVE
TAPPAN NY
10983
US

V. Phone/Fax

Practice location:
  • Phone: 845-365-6674
  • Fax:
Mailing address:
  • Phone: 845-365-6674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number366090-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: