Provider Demographics
NPI:1043618747
Name:DETULLIO, ALIX (APN)
Entity type:Individual
Prefix:
First Name:ALIX
Middle Name:
Last Name:DETULLIO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 ROUTE 9 N
Mailing Address - Street 2:SUITE B
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-8305
Mailing Address - Country:US
Mailing Address - Phone:732-431-0023
Mailing Address - Fax:
Practice Address - Street 1:901 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2537
Practice Address - Country:US
Practice Address - Phone:732-431-0023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00532200364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care