Healthcare Provider Details

I. General information

NPI: 1104070135
Provider Name (Legal Business Name): AMY DERICKS LOBER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 RTE 33 CARDIAC SURGERY
NEPTUNE NJ
07753-4859
US

IV. Provider business mailing address

41 STANFORD DR
HAZLET NJ
07730-2313
US

V. Phone/Fax

Practice location:
  • Phone: 732-776-4622
  • Fax:
Mailing address:
  • Phone: 858-752-2826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ00174700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00174700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: