Healthcare Provider Details

I. General information

NPI: 1689382210
Provider Name (Legal Business Name): BRIANNE KATHLEEN BOLJONIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 DOROTHY CT
MIDDLETOWN NJ
07748-1817
US

IV. Provider business mailing address

6 DOROTHY CT
MIDDLETOWN NJ
07748-1817
US

V. Phone/Fax

Practice location:
  • Phone: 540-385-6095
  • Fax:
Mailing address:
  • Phone: 540-385-6095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR23874900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number689552
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: