Provider Demographics
NPI:1053047621
Name:SIEGEL, MARIA CAMILLE BACCI
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:CAMILLE BACCI
Last Name:SIEGEL
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 1:1854 FRANKFORT AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-3192
Mailing Address - Country:US
Mailing Address - Phone:502-553-5371
Mailing Address - Fax:
Practice Address - Street 1:4414 CHURCHMAN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1152
Practice Address - Country:US
Practice Address - Phone:502-588-6449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY4011812363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program