1558516260 NPI number — NURSE PRACTITIONER PROFESSIONAL RESOURCES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558516260 NPI number — NURSE PRACTITIONER PROFESSIONAL RESOURCES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NURSE PRACTITIONER PROFESSIONAL RESOURCES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1558516260
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
202 CABOT CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEPTFORD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08096-5114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-669-8488
Provider Business Mailing Address Fax Number:
856-513-1377

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4361 ROUTE 42
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLACKWOOD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08012-1794
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-885-4579
Provider Business Practice Location Address Fax Number:
856-728-3513
Provider Enumeration Date:
11/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MANSOR
Authorized Official First Name:
MESHELL
Authorized Official Middle Name:
GLASGOW
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
856-885-4579

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  26NJ00097200 , 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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