Basic Information
| Provider Information | |||||||||
| NPI: | 1396767620 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | FUSILLO | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6050 1ST AVE S | ||||||||
| Address2: | APT 34 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337071636 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5509 GRAND BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346523836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272320644 | ||||||||
| FaxNumber: | 8885460488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 04/30/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP 1743292 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LG0600X | ARNP 1743292 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | 1396767620 | 01 | NPI | OTHER | 000977000 | 05 | FL | MEDICAID |