Healthcare Provider Details

I. General information

NPI: 1528483765
Provider Name (Legal Business Name): TERESA CIULLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 HOITT ST
SAN DIEGO CA
92102-3132
US

IV. Provider business mailing address

4721 LAMONT ST APT 16
SAN DIEGO CA
92109-3417
US

V. Phone/Fax

Practice location:
  • Phone: 619-262-7342
  • Fax:
Mailing address:
  • Phone: 607-427-9005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number12035
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: