Healthcare Provider Details

I. General information

NPI: 1942446893
Provider Name (Legal Business Name): PATRICIA MARY CONNOLLY-DETURA R.N., C.N.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/24/2008
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 E CLINTON AVE
BERGENFIELD NJ
07621-3024
US

IV. Provider business mailing address

114 E CLINTON AVE
BERGENFIELD NJ
07621-3024
US

V. Phone/Fax

Practice location:
  • Phone: 201-384-4955
  • Fax: 201-384-2559
Mailing address:
  • Phone: 201-384-4955
  • Fax: 201-384-2559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR05601200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number344654-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number25ME00016101
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberF000634-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: