Healthcare Provider Details

I. General information

NPI: 1417334772
Provider Name (Legal Business Name): VIRGINIE ELAINE PERNALA NP-C, MSN, CCRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIRGINIE ELAINE TAN

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE 5PE, ROOM 5949
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

30 PROSPECT AVE 5PE, ROOM 5949
HACKENSACK NJ
07601-1915
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00551600
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: