Healthcare Provider Details

I. General information

NPI: 1366745762
Provider Name (Legal Business Name): NICOLE ANN CIULLO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 N MAPLE AVE, SUITE B-10
MARLTON NJ
08053-9400
US

IV. Provider business mailing address

8 LAKEFIELD DR
MARLTON NJ
08053-5320
US

V. Phone/Fax

Practice location:
  • Phone: 215-637-3100
  • Fax:
Mailing address:
  • Phone: 856-520-5031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number959622
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: