Provider Demographics
NPI:1992483929
Name:CASTELLUCCIO, NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CASTELLUCCIO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 METRO BLVD
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-6101
Mailing Address - Country:US
Mailing Address - Phone:973-761-9000
Mailing Address - Fax:201-603-1993
Practice Address - Street 1:113 W ESSEX ST
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607-1023
Practice Address - Country:US
Practice Address - Phone:201-487-3400
Practice Address - Fax:201-603-1993
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MP00791700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant