Provider Demographics
NPI:1205824844
Name:PELLICCI, REGINA (CRNA)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:PELLICCI
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 W GERMANTOWN PIKE
Mailing Address - Street 2:STE 2
Mailing Address - City:EAST NORRITON
Mailing Address - State:PA
Mailing Address - Zip Code:19401-1382
Mailing Address - Country:US
Mailing Address - Phone:215-707-7992
Mailing Address - Fax:
Practice Address - Street 1:3509 N BROAD ST
Practice Address - Street 2:BOYER PAVILION, 2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-4105
Practice Address - Country:US
Practice Address - Phone:215-707-7992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN295975L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered