Healthcare Provider Details

I. General information

NPI: 1003572579
Provider Name (Legal Business Name): CAITLIN PROVOST CONLON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2021
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 BLEEKER ST
MILLBURN NJ
07041-1459
US

IV. Provider business mailing address

1 DIAMOND HILL RD
BERKELEY HEIGHTS NJ
07922-2104
US

V. Phone/Fax

Practice location:
  • Phone: 973-330-0810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ15336900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NR26902600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: