Healthcare Provider Details

I. General information

NPI: 1356092480
Provider Name (Legal Business Name): MADELINE KAYLIE DORESTIL APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 US HIGHWAY 22
SPRINGFIELD NJ
07081-3175
US

IV. Provider business mailing address

234 GLOBE AVE
UNION NJ
07083-7242
US

V. Phone/Fax

Practice location:
  • Phone: 973-381-0150
  • Fax:
Mailing address:
  • Phone: 862-218-8245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ01239300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: