Healthcare Provider Details

I. General information

NPI: 1912248675
Provider Name (Legal Business Name): MASSIEL GRULLON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1612 CENTRAL AVE STE 201
FAR ROCKAWAY NY
11691-4002
US

IV. Provider business mailing address

559 MILE SQUARE RD
YONKERS NY
10701-6345
US

V. Phone/Fax

Practice location:
  • Phone: 248-860-0211
  • Fax:
Mailing address:
  • Phone: 914-548-3033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number337140
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: