Provider Demographics
NPI:1053304998
Name:DITULLIO, MARY KATHLEEN (CRNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:DITULLIO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MERLINE AVE
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-1567
Mailing Address - Country:US
Mailing Address - Phone:814-868-9484
Mailing Address - Fax:814-866-5904
Practice Address - Street 1:17 MERLINE AVE
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-1567
Practice Address - Country:US
Practice Address - Phone:814-868-9484
Practice Address - Fax:814-866-5904
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP003581G363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1988988OtherBLUE SHIELD
PA1565773OtherGATEWAY
PAP00406374OtherRR MEDICARE
S42847Medicare UPIN
PA951883E7CMedicare PIN