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General NPI Number Information
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NPI Number | 1568795094
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Entity Type | Individual
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Provider Name | KELLY M BUCCI-DIDOMENICO
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Gender | Female
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Dates
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Enumeration Date | 09/16/2009
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Last Update Date | 12/09/2021
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Provider Practice Location Address
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Address Line | 479 HELEN ST
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City | BRIDGEPORT
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State | CT
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Zip | 06608-1321
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Country | US
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Telephone | 203-579-8310
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Fax | 203-683-3620
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Provider Business Mailing Address
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Address Line | 471 BARNUM AVE
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City | BRIDGEPORT
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State | CT
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Zip | 06608-2409
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Country | US
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Telephone | 203-576-3885
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Fax | 203-683-3620
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 1809
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License Number State | CT
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