Provider Demographics
NPI:1912730953
Name:KULLIE, EMMANUEL M
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:M
Last Name:KULLIE
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 1:185 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07017-2009
Mailing Address - Country:US
Mailing Address - Phone:973-687-8356
Mailing Address - Fax:
Practice Address - Street 1:185 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07017-2009
Practice Address - Country:US
Practice Address - Phone:973-687-8356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 3747A0650X
NJK92202257409922343900000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No347C00000XTransportation ServicesPrivate Vehicle