Provider Demographics
NPI:1962630657
Name:PORTELLI, PAULA (ACNP)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:PORTELLI
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 SOUTH RD
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-6027
Mailing Address - Country:US
Mailing Address - Phone:845-454-0120
Mailing Address - Fax:845-686-9016
Practice Address - Street 1:1910 SOUTH RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-6027
Practice Address - Country:US
Practice Address - Phone:845-454-0120
Practice Address - Fax:845-686-9016
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-01
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF430467363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03196792Medicaid
NYA400153564Medicare PIN