Healthcare Provider Details

I. General information

NPI: 1790089100
Provider Name (Legal Business Name): NICOLE LEE ZACOUR CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2010
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4247 ROUTE 9 N FREEHOLD OFFICE PLAZA BLDG #1
FREEHOLD NJ
07728-8307
US

IV. Provider business mailing address

4247 ROUTE 9 N FREEHOLD OFFICE PLAZA BLDG #1
FREEHOLD NJ
07728-8307
US

V. Phone/Fax

Practice location:
  • Phone: 732-780-7650
  • Fax: 732-780-8817
Mailing address:
  • Phone: 732-780-7650
  • Fax: 732-780-8817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN574736
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP011183
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00366000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: