Provider Demographics
NPI:1184716359
Name:GULLO, NICOLE (DC)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:GULLO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:GULLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3770 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-3837
Mailing Address - Country:US
Mailing Address - Phone:718-605-4093
Mailing Address - Fax:718-605-4104
Practice Address - Street 1:3770 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-3837
Practice Address - Country:US
Practice Address - Phone:718-605-4093
Practice Address - Fax:718-605-4104
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008155-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU60692Medicare UPIN
NYX66841Medicare ID - Type Unspecified