Healthcare Provider Details

I. General information

NPI: 1457695835
Provider Name (Legal Business Name): IN JIN LEE NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 PEHLE AVE STE 100
SADDLE BROOK NJ
07663-5227
US

IV. Provider business mailing address

143 BROADWAY
CRESSKILL NJ
07626-2150
US

V. Phone/Fax

Practice location:
  • Phone: 973-771-3560
  • Fax: 973-208-0851
Mailing address:
  • Phone: 551-202-9120
  • Fax: 201-492-5680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number306270
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number405458
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00411200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: