Provider Demographics
NPI:1699022830
Name:MARVULLO, KELLY TERESA
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:TERESA
Last Name:MARVULLO
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 1:43 DORCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1616
Mailing Address - Country:US
Mailing Address - Phone:631-278-2556
Mailing Address - Fax:
Practice Address - Street 1:43 DORCHESTER ROAD
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-1616
Practice Address - Country:US
Practice Address - Phone:631-278-2556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1135283174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist