Provider Demographics
NPI:1578677159
Name:RULLO, JENNY (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:RULLO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 404
Mailing Address - Street 2:C/O EMMC
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-0404
Mailing Address - Country:US
Mailing Address - Phone:207-973-4519
Mailing Address - Fax:207-992-4132
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:EMMC
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-973-4519
Practice Address - Fax:207-992-4132
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME021902367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM2136Medicare ID - Type Unspecified