Provider Demographics
NPI:1396767620
Name:FUSILLO, NANCY M (ARNP)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:M
Last Name:FUSILLO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6050 1ST AVE S
Mailing Address - Street 2:APT 34
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-1636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5509 GRAND BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-3836
Practice Address - Country:US
Practice Address - Phone:727-232-0644
Practice Address - Fax:888-546-0488
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1743292363LF0000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1396767620OtherNPI
FL000977000Medicaid
1396767620OtherNPI