Healthcare Provider Details

I. General information

NPI: 1760569982
Provider Name (Legal Business Name): SUSAN MARIE POPOLO BECKER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 01/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CEDAR CREST VILLAGE DR
POMPTON PLAINS NJ
07444-2100
US

IV. Provider business mailing address

813 MAIDEN CHOICE LN
CATONSVILLE MD
21228-3679
US

V. Phone/Fax

Practice location:
  • Phone: 973-831-3540
  • Fax: 973-831-3503
Mailing address:
  • Phone: 410-402-2257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNN105310
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: