Healthcare Provider Details

I. General information

NPI: 1215527874
Provider Name (Legal Business Name): NICOLE MARIE DOUGLAS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 ROUTE 24 STE E
CHESTER NJ
07930-2920
US

IV. Provider business mailing address

19 REDWOOD RD
MARTINSVILLE NJ
08836-2373
US

V. Phone/Fax

Practice location:
  • Phone: 908-879-1500
  • Fax:
Mailing address:
  • Phone: 732-977-8506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ01103800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: