Provider Demographics
NPI:1750136719
Name:GALLUCCI, ALISA (FNP)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:GALLUCCI
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:UNION BEACH
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-2819
Mailing Address - Country:US
Mailing Address - Phone:917-783-2090
Mailing Address - Fax:
Practice Address - Street 1:11 RALPH PL STE 112
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-4408
Practice Address - Country:US
Practice Address - Phone:718-954-2202
Practice Address - Fax:718-351-6848
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF35363901363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily