Healthcare Provider Details

I. General information

NPI: 1316255979
Provider Name (Legal Business Name): CAROL VASOLD CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. CAROL BANACH

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W WATER ST
TOMS RIVER NJ
08753-6407
US

IV. Provider business mailing address

PO BOX 4979
TOMS RIVER NJ
08754-4979
US

V. Phone/Fax

Practice location:
  • Phone: 732-244-4700
  • Fax: 732-244-8482
Mailing address:
  • Phone: 732-244-4700
  • Fax: 732-244-8482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP012103
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN575054
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR13660700
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP010720
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00376100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: