Healthcare Provider Details

I. General information

NPI: 1295077410
Provider Name (Legal Business Name): NICOLE SPANO NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 COURT ST
FREEHOLD NJ
07728
US

IV. Provider business mailing address

22 COURT ST
FREEHOLD NJ
07728-1700
US

V. Phone/Fax

Practice location:
  • Phone: 732-780-7387
  • Fax:
Mailing address:
  • Phone: 732-780-7387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number606476
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR14764800
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number402203
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ00810400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: