Healthcare Provider Details

I. General information

NPI: 1194283598
Provider Name (Legal Business Name): KRISTIE MARIE MASSUCCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 EDDY ST
PROVIDENCE RI
02905-4739
US

IV. Provider business mailing address

1000 EDDY ST
PROVIDENCE RI
02905-4739
US

V. Phone/Fax

Practice location:
  • Phone: 401-533-9100
  • Fax: 401-533-9105
Mailing address:
  • Phone: 401-533-9100
  • Fax: 401-533-9105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN57382
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: