Provider Demographics
NPI:1912248675
Name:GRULLON, MASSIEL
Entity Type:Individual
Prefix:
First Name:MASSIEL
Middle Name:
Last Name:GRULLON
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 1:191 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10703-2309
Mailing Address - Country:US
Mailing Address - Phone:914-548-3033
Mailing Address - Fax:
Practice Address - Street 1:2700 WESTCHESTER AVENUE
Practice Address - Street 2:
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577
Practice Address - Country:US
Practice Address - Phone:914-831-4160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33710363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily