Provider Demographics
NPI:1497946784
Name:SANTULLI, JEANNETTE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:JEANNETTE
Middle Name:
Last Name:SANTULLI
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 JACQUELINE WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-1206
Mailing Address - Country:US
Mailing Address - Phone:631-683-4199
Mailing Address - Fax:
Practice Address - Street 1:197 HALF HOLLOW RD
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-5861
Practice Address - Country:US
Practice Address - Phone:631-286-6935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY417230 1163W00000X
NYF401156-1163WP0807X
NYF4011561364SP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02077636Medicaid