Healthcare Provider Details

I. General information

NPI: 1174577746
Provider Name (Legal Business Name): NELLY GAVALAKIS APN-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 POLIFLY RD STE 112
HACKENSACK NJ
07601-1749
US

IV. Provider business mailing address

216 RAINBOW TER
BLACK MOUNTAIN NC
28711-8439
US

V. Phone/Fax

Practice location:
  • Phone: 201-996-8840
  • Fax: 201-441-9949
Mailing address:
  • Phone: 917-757-7261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5021153
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number20050002
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: