Provider Demographics
NPI:1700109006
Name:TRICOLLI, MARY BURKE (RN, LAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BURKE
Last Name:TRICOLLI
Suffix:
Gender:F
Credentials:RN, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MORTON SQ
Mailing Address - Street 2:#3CE
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-7800
Mailing Address - Country:US
Mailing Address - Phone:617-877-1004
Mailing Address - Fax:
Practice Address - Street 1:900 BROADWAY
Practice Address - Street 2:SUITE 404
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-1210
Practice Address - Country:US
Practice Address - Phone:617-877-1004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY623668-1163WX0200X
NY004240-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No163WX0200XNursing Service ProvidersRegistered NurseOncology