Healthcare Provider Details

I. General information

NPI: 1114566007
Provider Name (Legal Business Name): LAURA KATHRYN AVERY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2019
Last Update Date: 02/28/2024
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 POLIFLY RD
HACKENSACK NJ
07601-1758
US

IV. Provider business mailing address

155 POLIFLY RD STE 101
HACKENSACK NJ
07601-1749
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-8697
  • Fax: 201-441-9963
Mailing address:
  • Phone: 551-996-8697
  • Fax: 201-441-9963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ00948000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00948000
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: