Healthcare Provider Details

I. General information

NPI: 1720673171
Provider Name (Legal Business Name): MICCAL A. SCOTT-LYEW AGPC-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2021
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 VALLEY RD # 148
MONTCLAIR NJ
07042-2709
US

IV. Provider business mailing address

34 MOUNTAIN BLVD STE 203
WARREN NJ
07059-2640
US

V. Phone/Fax

Practice location:
  • Phone: 973-559-4600
  • Fax: 855-998-4358
Mailing address:
  • Phone: 908-574-1267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number26NJO1148500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: