Provider Demographics
NPI:1407871643
Name:RICCELLI, MARY S (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:RICCELLI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:S
Other - Last Name:CARISTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:488 PAWLING AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-5832
Mailing Address - Country:US
Mailing Address - Phone:720-317-9460
Mailing Address - Fax:877-268-5001
Practice Address - Street 1:10290 S PROGRESS WAY STE 208
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-9056
Practice Address - Country:US
Practice Address - Phone:720-317-9460
Practice Address - Fax:877-268-5001
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN0004954363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO41929705Medicaid
CO41929705Medicaid