Healthcare Provider Details

I. General information

NPI: 1952356149
Provider Name (Legal Business Name): SANTA CRISALL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 N 13TH ST
NEWARK NJ
07107-1317
US

IV. Provider business mailing address

222 KINDERKAMACK RD
ORADELL NJ
07649-2259
US

V. Phone/Fax

Practice location:
  • Phone: 973-268-2492
  • Fax:
Mailing address:
  • Phone: 973-268-2492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberNN71590
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: