Provider Demographics
NPI:1073009601
Name:COLUCCI, MARYGRACE E (NP)
Entity Type:Individual
Prefix:
First Name:MARYGRACE
Middle Name:E
Last Name:COLUCCI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 TWIN LN E
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-1963
Mailing Address - Country:US
Mailing Address - Phone:917-774-9152
Mailing Address - Fax:
Practice Address - Street 1:1703 MERRICK AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-1628
Practice Address - Country:US
Practice Address - Phone:516-378-3311
Practice Address - Fax:516-546-1517
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF341074-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily