Healthcare Provider Details

I. General information

NPI: 1215655782
Provider Name (Legal Business Name): PRECIOUS 134-04- NWIGWE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2022
Last Update Date: 09/29/2026
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1042 JOHN GLENN DR
HILLSIDE NJ
07205-2743
US

IV. Provider business mailing address

1042 JOHN GLENN DR
HILLSIDE NJ
07205-2743
US

V. Phone/Fax

Practice location:
  • Phone: 908-906-3491
  • Fax:
Mailing address:
  • Phone: 908-906-3491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number795333
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: