Provider Demographics
NPI:1649266156
Name:GRELLA, BETH A (NP)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:GRELLA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:A
Other - Last Name:ANDREWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:134 HOMER AVE
Mailing Address - Street 2:BOX 628
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-1206
Mailing Address - Country:US
Mailing Address - Phone:607-756-3561
Mailing Address - Fax:607-428-5142
Practice Address - Street 1:134 HOMER AVE
Practice Address - Street 2:BOX 628
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1206
Practice Address - Country:US
Practice Address - Phone:607-756-3561
Practice Address - Fax:607-428-5142
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302023363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P28610Medicare UPIN