Healthcare Provider Details

I. General information

NPI: 1265772842
Provider Name (Legal Business Name): JUSTINE DEVRIES REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2013
Last Update Date: 02/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 POMONA AVE
PORT REPUBLIC NJ
08241-9748
US

IV. Provider business mailing address

137 POMONA AVE
PORT REPUBLIC NJ
08241-9748
US

V. Phone/Fax

Practice location:
  • Phone: 609-709-0578
  • Fax: 609-296-1624
Mailing address:
  • Phone: 609-709-0578
  • Fax: 609-296-1624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR14542700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number26NR14542700
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: