Healthcare Provider Details

I. General information

NPI: 1346623915
Provider Name (Legal Business Name): NICOLE KEKESI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PEDERSEN CT
COLUMBUS NJ
08022-2257
US

IV. Provider business mailing address

1 PEDERSEN CT
COLUMBUS NJ
08022-2257
US

V. Phone/Fax

Practice location:
  • Phone: 609-468-8121
  • Fax:
Mailing address:
  • Phone: 609-468-8121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number940264
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number11146140
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: