Healthcare Provider Details

I. General information

NPI: 1902636194
Provider Name (Legal Business Name): MINSUNG JEONG MSN, APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2024
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22-02 BROADWAY STE 301
FAIR LAWN NJ
07410-3016
US

IV. Provider business mailing address

22-02 BROADWAY STE 301
FAIR LAWN NJ
07410-3016
US

V. Phone/Fax

Practice location:
  • Phone: 201-414-5732
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number707868
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR24535600
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number354927
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ15158300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: