Healthcare Provider Details

I. General information

NPI: 1346902996
Provider Name (Legal Business Name): GIOCONDA AESTHETICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 10/12/2021
Certification Date: 10/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 15TH ST APT 15M
FORT LEE NJ
07024-2030
US

IV. Provider business mailing address

1350 15TH ST APT 15M
FORT LEE NJ
07024-2030
US

V. Phone/Fax

Practice location:
  • Phone: 908-670-3322
  • Fax:
Mailing address:
  • Phone: 908-670-3322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LANA BUKLEY
Title or Position: PRESIDENT
Credential: NP
Phone: 908-670-3322