Healthcare Provider Details

I. General information

NPI: 1730573825
Provider Name (Legal Business Name): MICHELLE MINOCK APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 WILBUR AVE
HAMMONTON NJ
08037-1359
US

IV. Provider business mailing address

612 WILBUR AVE
HAMMONTON NJ
08037-1359
US

V. Phone/Fax

Practice location:
  • Phone: 609-214-4891
  • Fax:
Mailing address:
  • Phone: 609-214-4891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR15458700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00581200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: