Healthcare Provider Details

I. General information

NPI: 1740280395
Provider Name (Legal Business Name): ALICIA L. REALMUTO N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 RTE 138 STE 128
WALL TOWNSHIP NJ
07719-9694
US

IV. Provider business mailing address

3350 RTE 138 STE 128
WALL TOWNSHIP NJ
07719-9694
US

V. Phone/Fax

Practice location:
  • Phone: 904-862-7200
  • Fax:
Mailing address:
  • Phone: 732-280-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number26NJ00035100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: