Provider Demographics
NPI:1639283633
Name:MARTUCCI, LISA NICOLI (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:NICOLI
Last Name:MARTUCCI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17264 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5628
Mailing Address - Country:US
Mailing Address - Phone:949-724-0011
Mailing Address - Fax:949-724-0012
Practice Address - Street 1:17264 RED HILL AVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-5628
Practice Address - Country:US
Practice Address - Phone:949-724-0011
Practice Address - Fax:949-724-0012
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28504225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT28504Medicare ID - Type UnspecifiedPHYSICAL THERAPIST