Provider Demographics
NPI:1043217300
Name:TARALLO, PHYLLIS A (DNP,DCC,FNP-C)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:A
Last Name:TARALLO
Suffix:
Gender:F
Credentials:DNP,DCC,FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27036
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-7036
Mailing Address - Country:US
Mailing Address - Phone:212-305-0914
Mailing Address - Fax:212-305-4343
Practice Address - Street 1:718 TEANECK RD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4245
Practice Address - Country:US
Practice Address - Phone:212-305-0448
Practice Address - Fax:212-342-5600
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333859363LF0000X, 363LW0102X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0269026Medicaid
NYA400087968Medicare PIN