Healthcare Provider Details

I. General information

NPI: 1063458883
Provider Name (Legal Business Name): SUZANNE M MARCELLARO APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE FACULTY PRACTICE OFFICE
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

21 WALNUT ST
OAKLAND NJ
07436-2615
US

V. Phone/Fax

Practice location:
  • Phone: 201-996-2816
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00066700
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier311045
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerAMERIGROUP PIN
# 2
Identifier60026254
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerHORIZON NJ HEALTH
# 3
IdentifierO86O88ZFPY
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerCOGENT MEDICARE NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: