Provider Demographics
NPI:1699737189
Name:TULLER, CAROL BURNHAM (APRN)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:BURNHAM
Last Name:TULLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WATERVILLE RD
Mailing Address - Street 2:HARVEST HEALTHCARE C/O APPLE REHAB
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001
Mailing Address - Country:US
Mailing Address - Phone:860-678-9755
Mailing Address - Fax:860-284-6804
Practice Address - Street 1:21 WATERVILLE RD
Practice Address - Street 2:HARVEST HEALTHCARE C/O APPLE REHAB
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001
Practice Address - Country:US
Practice Address - Phone:860-678-9755
Practice Address - Fax:860-284-6804
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-03
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT000946363LA2200X
CT000946363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1699737189Medicaid
CT500001903Medicare PIN
CTS90734Medicare UPIN
CT500000330Medicare ID - Type UnspecifiedMEDICARE ID