Provider Demographics
NPI:1598363459
Name:GULLO, KRISTIN HEATHER (PNP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:HEATHER
Last Name:GULLO
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 LIDO PKWY
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-6017
Mailing Address - Country:US
Mailing Address - Phone:516-817-8011
Mailing Address - Fax:
Practice Address - Street 1:225 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5503
Practice Address - Country:US
Practice Address - Phone:516-829-9409
Practice Address - Fax:516-829-2713
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY383084363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY383084OtherNYS PEDIATRIC NURSE PRACTITIONER LICENSE