Provider Demographics
NPI:1194480103
Name:BULURO, MODUPE
Entity type:Individual
Prefix:MS
First Name:MODUPE
Middle Name:
Last Name:BULURO
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 1:151 BEACH 97TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11693-1323
Mailing Address - Country:US
Mailing Address - Phone:917-232-2082
Mailing Address - Fax:
Practice Address - Street 1:151 BEACH 97TH ST FL 1
Practice Address - Street 2:
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-1323
Practice Address - Country:US
Practice Address - Phone:917-232-2082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY618918-01163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY707-704-115OtherDRIVER LICENSE NUMBER