Healthcare Provider Details

I. General information

NPI: 1548212467
Provider Name (Legal Business Name): BONNIE MATOSSIAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E RIDGEWOOD AVE
RIDGEWOOD NJ
07450-3957
US

IV. Provider business mailing address

1200 E RIDGEWOOD AVE
RIDGEWOOD NJ
07450-3957
US

V. Phone/Fax

Practice location:
  • Phone: 201-670-8660
  • Fax: 201-670-6693
Mailing address:
  • Phone: 201-670-8660
  • Fax: 201-670-6693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ00056000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: