Provider Demographics
NPI:1336194794
Name:ABRUNZO, NICOLE M (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:ABRUNZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9484
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02940-9484
Mailing Address - Country:US
Mailing Address - Phone:401-854-2500
Mailing Address - Fax:401-854-2519
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:CLAVERICK 2
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-854-2504
Practice Address - Fax:401-854-2519
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-114235208000000X
RIMD12710208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1992758544OtherCMMG GROUP NPI
RINA72114Medicaid
RI9/11/2008OtherNHPRI
RI1336194794OtherNPI
MA2159287Medicaid
MA12/29/2008OtherTUFTS HEALTH PLAN
RI007060380OtherRI MEDICARE
RI04/15/2009OtherUNITED HEALTHCARE
IL036114235Medicaid