Provider Demographics
NPI:1366745762
Name:CIULLO, NICOLE ANN (RD)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANN
Last Name:CIULLO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 LAKEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-5320
Mailing Address - Country:US
Mailing Address - Phone:856-520-5031
Mailing Address - Fax:
Practice Address - Street 1:230 N MAPLE AVE, SUITE B-10
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-9400
Practice Address - Country:US
Practice Address - Phone:215-637-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-07
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ959622133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ469427OtherMEDICARE-NJ PTAN