Healthcare Provider Details

I. General information

NPI: 1558516260
Provider Name (Legal Business Name): NURSE PRACTITIONER PROFESSIONAL RESOURCES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2008
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4361 ROUTE 42
BLACKWOOD NJ
08012-1794
US

IV. Provider business mailing address

202 CABOT CT
DEPTFORD NJ
08096-5114
US

V. Phone/Fax

Practice location:
  • Phone: 856-885-4579
  • Fax: 856-728-3513
Mailing address:
  • Phone: 856-669-8488
  • Fax: 856-513-1377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00097200
License Number StateNJ

VIII. Authorized Official

Name: MESHELL GLASGOW MANSOR
Title or Position: OWNER
Credential: APN
Phone: 856-885-4579