Healthcare Provider Details

I. General information

NPI: 1356063309
Provider Name (Legal Business Name): DIKSHYA KOIRALA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 VALLEY RD # 3148
MONTCLAIR NJ
07042-2709
US

IV. Provider business mailing address

1301 MAIN ST
ASBURY PARK NJ
07712-5359
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ01368000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: