Provider Demographics
NPI:1194283598
Name:MASSUCCI, KRISTIE MARIE
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:MARIE
Last Name:MASSUCCI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 EDDY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4739
Mailing Address - Country:US
Mailing Address - Phone:401-533-9100
Mailing Address - Fax:401-533-9105
Practice Address - Street 1:1000 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-4739
Practice Address - Country:US
Practice Address - Phone:401-533-9100
Practice Address - Fax:401-533-9105
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN57382163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0614OtherNEIGHBORHOOD HEALTH
RIES01788Medicaid
RISB870OtherBLUE CROSS