=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912248675
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MASSIEL GRULLON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2013
-----------------------------------------------------
Last Update Date | 03/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2700 WESTCHESTER AVENUE
-----------------------------------------------------
City | PURCHASE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-831-4160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 191 LAKE AVE
-----------------------------------------------------
City | YONKERS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10703-2309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-548-3033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 33710
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------