Healthcare Provider Details

I. General information

NPI: 1649823519
Provider Name (Legal Business Name): NICOLE PIVONKA BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 ROUTE 73 STE B
VOORHEES NJ
08043-9539
US

IV. Provider business mailing address

301 LIPPINCOTT DR STE 410
MARLTON NJ
08053-4197
US

V. Phone/Fax

Practice location:
  • Phone: 856-247-7230
  • Fax: 856-247-7231
Mailing address:
  • Phone: 856-355-0340
  • Fax: 856-355-0330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number26NR18617100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ00986300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: