Healthcare Provider Details

I. General information

NPI: 1003537408
Provider Name (Legal Business Name): LORI SHAKOUR FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 PARAGON WAY STE 300
FREEHOLD NJ
07728-7805
US

IV. Provider business mailing address

363 LODI CT
BELFORD NJ
07718-1016
US

V. Phone/Fax

Practice location:
  • Phone: 732-462-9800
  • Fax:
Mailing address:
  • Phone: 908-601-6544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ01351000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: