Healthcare Provider Details

I. General information

NPI: 1417365776
Provider Name (Legal Business Name): NASHANDA BALOGUN AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 VALLEY RD # 148
MONTCLAIR NJ
07042-2709
US

IV. Provider business mailing address

28 VALLEY RD # 148
MONTCLAIR NJ
07042-2709
US

V. Phone/Fax

Practice location:
  • Phone: 973-559-4600
  • Fax: 855-998-4358
Mailing address:
  • Phone: 973-559-4600
  • Fax: 855-998-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP013879
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberSP013879
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ15053300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: