Healthcare Provider Details

I. General information

NPI: 1376726562
Provider Name (Legal Business Name): MS. HATTIE LUCILLE OSBORNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 FREEMAN AVE
EAST ORANGE NJ
07018-2704
US

IV. Provider business mailing address

385 TREMONT AVE
EAST ORANGE NJ
07018-1023
US

V. Phone/Fax

Practice location:
  • Phone: 973-675-0481
  • Fax:
Mailing address:
  • Phone: 973-676-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number26N005459000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: