MEDICARE: KATHY ELLARENE NOVELLA PROCTOR MS, BSN, RN- CCM

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	163WC0400X	Case Management Registered Nurse	26NR22095100	NJ
2	163WC0400X	Case Management Registered Nurse	543566	NY
3	390200000X	Student in an Organized Health Care Education/Training Program
4	133NN1002X	Nutrition Education Nutritionist

General Provider Information

NPI Number	:	1962121251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHY ELLARENE NOVELLA PROCTOR MS, BSN, RN- CCM

Provider Business Mailing Address
First Line	:	182 E LINDEN AVE
Second Line	:
City	:	DUMONT
State	:	NJ
Zip	:	07628-1916
Country	:	US
Telephone Number	:	646-401-3115
Fax Number	:	201-330-4645

Provider Business Practice Location Address
First Line	:	182 E LINDEN AVE
Second Line	:
City	:	DUMONT
State	:	NJ
Zip	:	07628-1916
Country	:	US
Telephone Number	:	646-401-3115
Fax Number	:	201-330-4645

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

Provider Enumeration Date	:	08/22/2022
Last Update Date	:	02/25/2024

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