Provider Demographics
NPI:1043748478
Name:PETRULLO, CARLA (RN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:PETRULLO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CHAMPLAIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-3926
Mailing Address - Country:US
Mailing Address - Phone:718-987-8559
Mailing Address - Fax:
Practice Address - Street 1:1477 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1906
Practice Address - Country:US
Practice Address - Phone:718-979-6900
Practice Address - Fax:718-979-6940
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-30
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257940163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty