Healthcare Provider Details

I. General information

NPI: 1073848651
Provider Name (Legal Business Name): PRIYA R LAD R.N., CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PRIYA B CHAMPANERIA RN, CPNP

II. Dates (important events)

Enumeration Date: 10/15/2009
Last Update Date: 01/12/2012
Certification Date:
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: 732-363-6656
Mailing address:
  • Phone: 732-363-6655
  • Fax: 732-363-6656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number26NJ00321300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN0000167674
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: