Provider Demographics
NPI:1336534114
Name:GUALLPA, BRAULIO FERNANDO (LPN)
Entity type:Individual
Prefix:
First Name:BRAULIO
Middle Name:FERNANDO
Last Name:GUALLPA
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:674 MAIN ST
Mailing Address - Street 2:FL. 2
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10566-2013
Mailing Address - Country:US
Mailing Address - Phone:914-930-9313
Mailing Address - Fax:
Practice Address - Street 1:674 MAIN ST
Practice Address - Street 2:FL. 2
Practice Address - City:PEEKSKILL
Practice Address - State:NY
Practice Address - Zip Code:10566-2013
Practice Address - Country:US
Practice Address - Phone:914-930-9313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321073164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse