Healthcare Provider Details

I. General information

NPI: 1104334655
Provider Name (Legal Business Name): KELLY VANWYCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 ROUTE 10 STE 205
RANDOLPH NJ
07869-2144
US

IV. Provider business mailing address

700 ROUTE 46 E STE 450
FAIRFIELD NJ
07004-1583
US

V. Phone/Fax

Practice location:
  • Phone: 973-560-9500
  • Fax:
Mailing address:
  • Phone: 973-559-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00792600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: