Provider Demographics
NPI:1083871842
Name:DULLEA, LINDA A
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:A
Last Name:DULLEA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 BROOK ST
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1804
Mailing Address - Country:US
Mailing Address - Phone:631-589-6646
Mailing Address - Fax:
Practice Address - Street 1:133 BROOK ST
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1804
Practice Address - Country:US
Practice Address - Phone:631-589-6646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY408430-1163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02886262Medicaid