Provider Demographics
NPI:1518916329
Name:MUCCI, HEATHER J (ARNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:J
Last Name:MUCCI
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36422
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40233-6422
Mailing Address - Country:US
Mailing Address - Phone:502-583-6647
Mailing Address - Fax:
Practice Address - Street 1:444 S 1ST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1416
Practice Address - Country:US
Practice Address - Phone:502-583-6647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40176363L00000X
KY4440P207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78013695Medicaid
KYP00343544OtherRR MCR
KY0754904Medicare PIN
KYP00343544OtherRR MCR