Healthcare Provider Details

I. General information

NPI: 1437803186
Provider Name (Legal Business Name): GABRIELLE TANTILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 02/10/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 METRO BLVD
NUTLEY NJ
07110-6101
US

IV. Provider business mailing address

90 COMPTON AVE
HAZLET TOWNSHIP NJ
07734-3111
US

V. Phone/Fax

Practice location:
  • Phone: 973-761-9000
  • Fax:
Mailing address:
  • Phone: 732-778-0587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: