Healthcare Provider Details

I. General information

NPI: 1881634731
Provider Name (Legal Business Name): LAUREL L. BALLENTINE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 08/23/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COOPER PLZ
CAMDEN NJ
08103
US

IV. Provider business mailing address

1 FEDERAL ST # 200
CAMDEN NJ
08103-1088
US

V. Phone/Fax

Practice location:
  • Phone: 856-342-2351
  • Fax:
Mailing address:
  • Phone: 856-356-4924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNJ00057400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNJ00057400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: