Healthcare Provider Details

I. General information

NPI: 1851790992
Provider Name (Legal Business Name): KAITLIN RODRIGUEZ APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 2ND ST
LAKEWOOD NJ
08701-3324
US

IV. Provider business mailing address

101 2ND ST
LAKEWOOD NJ
08701-3324
US

V. Phone/Fax

Practice location:
  • Phone: 732-363-6655
  • Fax: 732-901-0277
Mailing address:
  • Phone: 732-363-6655
  • Fax: 732-901-0277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR14432100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9444701
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number26NJ00484000
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number9444701
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number26NJ00484000
License Number StateNJ
# 6
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAC002942
License Number StateMD
# 7
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number9444701
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: