Provider Demographics
NPI:1194084947
Name:PELERIN, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:PELERIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 HAWTHORNE ST APT 3E
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-5732
Mailing Address - Country:US
Mailing Address - Phone:347-600-8030
Mailing Address - Fax:
Practice Address - Street 1:13 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-6003
Practice Address - Country:US
Practice Address - Phone:516-823-0739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302861-1164W00000X
NJ26NP06416100164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse