1124520713 NPI number — BETHANY LAUREN NYSTRAND-IBANEZ APN

Table of content: BETHANY LAUREN NYSTRAND-IBANEZ APN (NPI 1124520713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124520713 NPI number — BETHANY LAUREN NYSTRAND-IBANEZ APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NYSTRAND-IBANEZ
Provider First Name:
BETHANY
Provider Middle Name:
LAUREN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124520713
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 WELSH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08833-4317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-391-1310
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
228 MOUNTAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HACKETTSTOWN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07840-2409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-852-2470
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  26NJ00785800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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