Provider Demographics
NPI:1558170431
Name:PUCCINELLI, NINA
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:PUCCINELLI
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 1:2754 N HAMPDEN CT
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1651
Mailing Address - Country:US
Mailing Address - Phone:630-277-2246
Mailing Address - Fax:
Practice Address - Street 1:2940 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-8905
Practice Address - Country:US
Practice Address - Phone:773-348-4155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051306647183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist