Provider Demographics
NPI:1851656391
Name:PUCCIO, JOLENE W
Entity Type:Individual
Prefix:MRS
First Name:JOLENE
Middle Name:W
Last Name:PUCCIO
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 1:3256 WATERBURY DRIVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793
Mailing Address - Country:US
Mailing Address - Phone:516-785-4772
Mailing Address - Fax:
Practice Address - Street 1:3256 WATERBURY DR
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3332
Practice Address - Country:US
Practice Address - Phone:516-785-4772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1868813174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist