Provider Demographics
NPI:1285805820
Name:PUCILLO, JEANNE-MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JEANNE-MARIE
Middle Name:
Last Name:PUCILLO
Suffix:
Gender:F
Credentials:PA-C
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 425
Mailing Address - Street 2:
Mailing Address - City:LEDERACH
Mailing Address - State:PA
Mailing Address - Zip Code:19450-0425
Mailing Address - Country:US
Mailing Address - Phone:610-482-4949
Mailing Address - Fax:610-482-4950
Practice Address - Street 1:541 S OXFORD VALLEY RD
Practice Address - Street 2:
Practice Address - City:FAIRLESS HILLS
Practice Address - State:PA
Practice Address - Zip Code:19030-2612
Practice Address - Country:US
Practice Address - Phone:267-202-6433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-21
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA220174Medicare PIN