Healthcare Provider Details

I. General information

NPI: 1225993488
Provider Name (Legal Business Name): JESSICA ANN GULLO LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 BRIGHT ST
LOCKPORT NY
14094-4103
US

IV. Provider business mailing address

3700 KELSEY LN
NORTH TONAWANDA NY
14120-3617
US

V. Phone/Fax

Practice location:
  • Phone: 716-480-6889
  • Fax:
Mailing address:
  • Phone: 716-480-6889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number352948
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: