Healthcare Provider Details

I. General information

NPI: 1487691523
Provider Name (Legal Business Name): NICOLINA PENTRELLI DERACO LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLINA PENTRELLI LPT

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 08/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 EAGLE ROCK AVE
EAST HANOVER NJ
07936-3167
US

IV. Provider business mailing address

11 EAGLE ROCK AVE
EAST HANOVER NJ
07936-3167
US

V. Phone/Fax

Practice location:
  • Phone: 197-388-7900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number022136-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: