Healthcare Provider Details

I. General information

NPI: 1437568193
Provider Name (Legal Business Name): WOMEN'S HEALTH COLLABORATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 BROAD ST
CLIFTON NJ
07013-1645
US

IV. Provider business mailing address

716 BROAD ST
CLIFTON NJ
07013-1645
US

V. Phone/Fax

Practice location:
  • Phone: 201-567-0810
  • Fax: 973-928-2912
Mailing address:
  • Phone: 201-567-0810
  • Fax: 973-928-2912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number25ME00056001
License Number StateNJ

VIII. Authorized Official

Name: DEDRA SALLY
Title or Position: CERTIFIED NURSE-MIDWIFE
Credential: CNM, MSN
Phone: 215-205-6758