=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285605949
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY JULIE CROCCO CNM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2006
-----------------------------------------------------
Last Update Date | 05/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4422 3RD AVE DEPARTMENT OF OBSTETRICS & GYNECOLOGY
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10457-2545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-960-9415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4422 3RD AVE DEPARTMENT OF OBSTETRICS & GYNECOLOGY
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10457-2545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-960-9415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number | 000124
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number | 000158
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------