Provider Demographics
NPI:1831813013
Name:CRETELLA, VINCENT (RN)
Entity type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:
Last Name:CRETELLA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CRYSTAL STREET
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701
Mailing Address - Country:US
Mailing Address - Phone:845-707-4326
Mailing Address - Fax:845-707-4398
Practice Address - Street 1:20 CRYSTAL STREET
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701
Practice Address - Country:US
Practice Address - Phone:845-707-4326
Practice Address - Fax:845-707-4398
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303215-01364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03308192Medicaid