Healthcare Provider Details

I. General information

NPI: 1558910984
Provider Name (Legal Business Name): MICHELLE LEE EISENHAUER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELLE LEE RUDDY RN

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 STOCKTON DR
TOMS RIVER NJ
08755-6433
US

IV. Provider business mailing address

PO BOX 142
LANOKA HARBOR NJ
08734-0142
US

V. Phone/Fax

Practice location:
  • Phone: 732-363-6655
  • Fax: 732-363-6656
Mailing address:
  • Phone: 732-674-6639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00956300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: