Healthcare Provider Details

I. General information

NPI: 1124727888
Provider Name (Legal Business Name): JUSTIN MASTRUCCI FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2023
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 W MARKET ST STE 200
FAIRLAWN OH
44333-4540
US

IV. Provider business mailing address

23951 DELMERE DR
NORTH OLMSTED OH
44070-1573
US

V. Phone/Fax

Practice location:
  • Phone: 330-666-2700
  • Fax:
Mailing address:
  • Phone: 810-394-5906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0032261
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: