Provider Demographics
NPI:1023290384
Name:MARCUCCIO, MICHELE J (RD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:J
Last Name:MARCUCCIO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:J
Other - Last Name:MCERLAEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:PROVIDER ENROLLMENT -- RT. 1022
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-5302
Mailing Address - Country:US
Mailing Address - Phone:409-747-0890
Mailing Address - Fax:409-747-1023
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-5302
Practice Address - Country:US
Practice Address - Phone:409-772-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80525133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered