Basic Information
| Provider Information | |||||||||
| NPI: | 1710374178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINICUCCI | ||||||||
| FirstName: | ANNETTE | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRIFFING | ||||||||
| OtherFirstName: | ANNETTE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 29500 HEATHERCLIFF RD SPC 217 | ||||||||
| Address2: | |||||||||
| City: | MALIBU | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902656217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107139179 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2791 AGOURA RD | ||||||||
| Address2: | |||||||||
| City: | THOUSAND OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913613101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8886947287 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2015 | ||||||||
| LastUpdateDate: | 03/24/2016 | ||||||||
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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 | 363LF0000X | 424458 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.