Healthcare Provider Details

I. General information

NPI: 1801499124
Provider Name (Legal Business Name): MICHELLE PATRICIA SWEENEY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE 2ND FLOOR, IMUS PEDIATRIC CENTER
HACKENSACK NJ
07601-0760
US

IV. Provider business mailing address

3600 ROUTE 66 FL 3
NEPTUNE NJ
07753-2645
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-5329
  • Fax:
Mailing address:
  • Phone: 732-807-0800
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86093801
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: