Healthcare Provider Details

I. General information

NPI: 1790374437
Provider Name (Legal Business Name): JOANNA BUILES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2021
Last Update Date: 01/17/2021
Certification Date: 09/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 N VAN DIEN AVE
RIDGEWOOD NJ
07450-2736
US

IV. Provider business mailing address

124 HOME PL UNIT 17
LODI NJ
07644-1557
US

V. Phone/Fax

Practice location:
  • Phone: 201-447-8000
  • Fax:
Mailing address:
  • Phone: 201-993-0324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ01104700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: