Healthcare Provider Details

I. General information

NPI: 1023614658
Provider Name (Legal Business Name): NICOLE LOREN GROSSBARD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 GRAND AVE STE 137
RIVER EDGE NJ
07661-1930
US

IV. Provider business mailing address

41 BROWNSTONE WAY APT 209
ENGLEWOOD NJ
07631-1211
US

V. Phone/Fax

Practice location:
  • Phone: 201-696-2646
  • Fax: 201-485-6570
Mailing address:
  • Phone: 845-558-7229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number717409
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NR22658200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: