Healthcare Provider Details

I. General information

NPI: 1679135925
Provider Name (Legal Business Name): KRISTEN POLENTARUTTI P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2019
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 US HIGHWAY 46 STE 100
MINE HILL NJ
07803-3163
US

IV. Provider business mailing address

1130 MCBRIDE AVE FL 3
WOODLAND PARK NJ
07424-3806
US

V. Phone/Fax

Practice location:
  • Phone: 973-366-7330
  • Fax:
Mailing address:
  • Phone: 973-785-2277
  • Fax: 973-785-2355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00530100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: