Healthcare Provider Details

I. General information

NPI: 1750273256
Provider Name (Legal Business Name): ULIANA FATEEV APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2025
Last Update Date: 07/20/2025
Certification Date: 07/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 CHESTNUT ST STE 102
LAKEWOOD NJ
08701-6124
US

IV. Provider business mailing address

96 ALPINE TRL
SPARTA NJ
07871-1529
US

V. Phone/Fax

Practice location:
  • Phone: 732-282-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26NJ15161500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number26NJ15161500
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number26NJ15161500
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ15161500
License Number StateNJ
# 5
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ15161500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: