Healthcare Provider Details

I. General information

NPI: 1972983062
Provider Name (Legal Business Name): KATHY COURAIN APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 PASSAIC AVE
NUTLEY NJ
07110-2738
US

IV. Provider business mailing address

200 ROBIN RD
PARAMUS NJ
07652-1414
US

V. Phone/Fax

Practice location:
  • Phone: 973-667-8889
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number26NO06767100
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0964034
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: