Provider Demographics
NPI:1174348064
Name:PUCCIO, ANAISSA
Entity type:Individual
Prefix:MRS
First Name:ANAISSA
Middle Name:
Last Name:PUCCIO
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 1:12220 SUMMER LN
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90602-1091
Mailing Address - Country:US
Mailing Address - Phone:323-474-7042
Mailing Address - Fax:
Practice Address - Street 1:12462 PUTNAM ST STE 303
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1049
Practice Address - Country:US
Practice Address - Phone:562-789-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032964363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily