Provider Demographics
NPI:1356789549
Name:RISTUCCIA, MICHELLE BERNICE (PA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BERNICE
Last Name:RISTUCCIA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 16149
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:RI
Mailing Address - Zip Code:02916-0697
Mailing Address - Country:US
Mailing Address - Phone:401-453-9625
Mailing Address - Fax:401-435-7069
Practice Address - Street 1:227 CENTERVILLE RD STE 2
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4394
Practice Address - Country:US
Practice Address - Phone:401-736-3731
Practice Address - Fax:401-732-8484
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
RIPA00714363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical