=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508324831
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN CARULLO CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2019
-----------------------------------------------------
Last Update Date | 10/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3737 MARKET ST STE 1220
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-5545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-902-4989
-----------------------------------------------------
Fax | 215-222-6658
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3737 MARKET ST STE 1220
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-5545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-902-4989
-----------------------------------------------------
Fax | 215-615-5319
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | SP020058
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------