Healthcare Provider Details

I. General information

NPI: 1912882937
Provider Name (Legal Business Name): REBECCA WENDE
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 PARK AVE
EAST ORANGE NJ
07017-1905
US

IV. Provider business mailing address

613 PARK AVE
EAST ORANGE NJ
07017-1905
US

V. Phone/Fax

Practice location:
  • Phone: 973-672-8573
  • Fax:
Mailing address:
  • Phone: 973-672-8573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number836819-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ15381200
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR22417000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: