Provider Demographics
NPI:1417366360
Name:DIFUCCI, CARLEE
Entity Type:Individual
Prefix:
First Name:CARLEE
Middle Name:
Last Name:DIFUCCI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 MYRTLE ST
Mailing Address - Street 2:SUITE 290
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-4602
Mailing Address - Country:US
Mailing Address - Phone:814-454-1142
Mailing Address - Fax:814-454-1255
Practice Address - Street 1:2315 MYRTLE ST
Practice Address - Street 2:SUITE 290
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-4602
Practice Address - Country:US
Practice Address - Phone:814-454-1142
Practice Address - Fax:814-454-1255
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATMA052931363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant