Healthcare Provider Details

I. General information

NPI: 1659793875
Provider Name (Legal Business Name): MICHELE BOONSTRA MSN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 SECOND ST
HACKENSACK NJ
07601
US

IV. Provider business mailing address

92 SECOND ST
HACKENSACK NJ
07601
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-5900
  • Fax:
Mailing address:
  • Phone: 551-996-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00467100
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: