Provider Demographics
NPI:1033238910
Name:GRULLON, JINETTE (MPAS RPA-C)
Entity Type:Individual
Prefix:MS
First Name:JINETTE
Middle Name:
Last Name:GRULLON
Suffix:
Gender:F
Credentials:MPAS RPA-C
Other - Prefix:MS
Other - First Name:JINETTE
Other - Middle Name:
Other - Last Name:VILLANUEVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPAS RPA-C
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-0418
Mailing Address - Country:US
Mailing Address - Phone:347-964-5279
Mailing Address - Fax:347-964-5279
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011113363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant