Healthcare Provider Details

I. General information

NPI: 1396313680
Provider Name (Legal Business Name): GEORGE KOFA KIEH PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 N BLACK HORSE PIKE
RUNNEMEDE NJ
08078-1034
US

IV. Provider business mailing address

292 APPLEGARTH RD
MONROE TOWNSHIP NJ
08831-3754
US

V. Phone/Fax

Practice location:
  • Phone: 215-839-0801
  • Fax:
Mailing address:
  • Phone: 609-532-9965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ01160100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: