Provider Demographics
NPI:1588826465
Name:MINICUCCI, ELIZABETH ANN (CNMW)
Entity Type:Individual
Prefix:MISS
First Name:ELIZABETH
Middle Name:ANN
Last Name:MINICUCCI
Suffix:
Gender:F
Credentials:CNMW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WEST ARBOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103
Mailing Address - Country:US
Mailing Address - Phone:619-543-2533
Mailing Address - Fax:619-543-2366
Practice Address - Street 1:200 WEST ARBOR DRIVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:619-543-2533
Practice Address - Fax:619-543-2366
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 698108367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife