1184199382 NPI number — ROSENNA DAVITA HINNANT PEMBERTON LPC

Table of content: ROSENNA DAVITA HINNANT PEMBERTON LPC (NPI 1184199382)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184199382 NPI number — ROSENNA DAVITA HINNANT PEMBERTON LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEMBERTON
Provider First Name:
ROSENNA
Provider Middle Name:
DAVITA HINNANT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
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:
1184199382
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
95 W 13TH ST FL 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAYONNE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07002-1343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-304-7957
Provider Business Mailing Address Fax Number:
201-510-0758

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
95 W 13TH ST FL 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAYONNE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07002-1343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-668-1001
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2018

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: 101YP2500X , with the licence number:  37PC00630300 , 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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