Provider Demographics
NPI:1528642915
Name:TULLOCH, GLENESE A
Entity type:Individual
Prefix:
First Name:GLENESE
Middle Name:A
Last Name:TULLOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 MORGAN CT
Mailing Address - Street 2:
Mailing Address - City:CENTRAL VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10917-3524
Mailing Address - Country:US
Mailing Address - Phone:718-629-7484
Mailing Address - Fax:
Practice Address - Street 1:7 MORGAN CT
Practice Address - Street 2:
Practice Address - City:CENTRAL VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10917-3524
Practice Address - Country:US
Practice Address - Phone:718-629-7484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341655363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily