Provider Demographics
NPI:1043836513
Name:GRULLON, SASHA PIERINA (NP)
Entity Type:Individual
Prefix:
First Name:SASHA
Middle Name:PIERINA
Last Name:GRULLON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 CONGRESS ST STE 513
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-5523
Mailing Address - Country:US
Mailing Address - Phone:978-744-8388
Mailing Address - Fax:
Practice Address - Street 1:47 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-7308
Practice Address - Country:US
Practice Address - Phone:978-744-8388
Practice Address - Fax:978-740-2339
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2280781363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110163084AMedicaid