Provider Demographics
NPI:1477947877
Name:GRULLON, GENESIS (RN, NP)
Entity Type:Individual
Prefix:
First Name:GENESIS
Middle Name:
Last Name:GRULLON
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 W 180TH ST
Mailing Address - Street 2:APT 5
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3543
Mailing Address - Country:US
Mailing Address - Phone:917-405-5490
Mailing Address - Fax:
Practice Address - Street 1:803 W 180TH ST
Practice Address - Street 2:APT 5
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3543
Practice Address - Country:US
Practice Address - Phone:917-405-5490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY672663163W00000X
NY340240363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse