Provider Demographics
NPI:1851123319
Name:GARDULLO, ALEXIS SELENE
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:SELENE
Last Name:GARDULLO
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 1:505 W EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-5013
Mailing Address - Country:US
Mailing Address - Phone:620-249-5973
Mailing Address - Fax:
Practice Address - Street 1:1111 E TUOLUMNE RD
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-1541
Practice Address - Country:US
Practice Address - Phone:209-632-7577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
CA6243224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant