Healthcare Provider Details

I. General information

NPI: 1295353712
Provider Name (Legal Business Name): ANGELO LLANES MSN, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2020
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 GRAND ST
JERSEY CITY NJ
07302-4321
US

IV. Provider business mailing address

171 FOWLER AVE
JERSEY CITY NJ
07305-2025
US

V. Phone/Fax

Practice location:
  • Phone: 201-915-2000
  • Fax:
Mailing address:
  • Phone: 201-467-6101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number26NR16229100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number73279301
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NJ01389600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: