Basic Information
| Provider Information | |||||||||
| NPI: | 1649462391 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PICUCCI | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22487 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457226 | ||||||||
| FaxNumber: | 9204457229 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 EAST BLVD | ||||||||
| Address2: | |||||||||
| City: | KINGSFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498024436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067744000 | ||||||||
| FaxNumber: | 9067740088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 10/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101017482 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.