Provider Demographics
NPI:1255815882
Name:FUCIARELLI, AMY-BETH MARGUERITE (NP)
Entity type:Individual
Prefix:
First Name:AMY-BETH
Middle Name:MARGUERITE
Last Name:FUCIARELLI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34815 W MICHIGAN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1895
Mailing Address - Country:US
Mailing Address - Phone:734-713-7189
Mailing Address - Fax:734-263-1985
Practice Address - Street 1:34815 W MICHIGAN AVE STE 1
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184
Practice Address - Country:US
Practice Address - Phone:734-713-7189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704272593363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology