Healthcare Provider Details

I. General information

NPI: 1477199446
Provider Name (Legal Business Name): ANGELIC PRIMARY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8025 BLACK HORSE PIKE STE 501
PLEASANTVILLE NJ
08232-2967
US

IV. Provider business mailing address

PO BOX 313
LINWOOD NJ
08221-0313
US

V. Phone/Fax

Practice location:
  • Phone: 854-600-9684
  • Fax: 609-415-1875
Mailing address:
  • Phone: 854-600-9684
  • Fax: 609-415-1875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. JANET GIBSON
Title or Position: OWNER/DIRECTOR
Credential: APN
Phone: 609-515-4759