MEDICARE: MISS MADELINE KAYLIE DORESTIL APN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	26NJ01239300	NJ

General Provider Information

NPI Number	:	1356092480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MADELINE KAYLIE DORESTIL APN

Provider Business Mailing Address
First Line	:	234 GLOBE AVE
Second Line	:
City	:	UNION
State	:	NJ
Zip	:	07083-7242
Country	:	US
Telephone Number	:	862-218-8245
Fax Number	:

Provider Business Practice Location Address
First Line	:	126 US HIGHWAY 22
Second Line	:
City	:	SPRINGFIELD
State	:	NJ
Zip	:	07081-3175
Country	:	US
Telephone Number	:	973-381-0150
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2022
Last Update Date	:	01/11/2022

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