Healthcare Provider Details

I. General information

NPI: 1316539240
Provider Name (Legal Business Name): JESSICA ELIZABETH SORRENTINO APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
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:
Mailing address:
  • Phone: 732-363-6655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ01093200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: