Healthcare Provider Details

I. General information

NPI: 1053657411
Provider Name (Legal Business Name): SE YOUNG OH APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2012
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 STATE ROUTE 23 STE 250
WAYNE NJ
07470-7520
US

IV. Provider business mailing address

1680 ROUTE 23 STE 250
WAYNE NJ
07470-7520
US

V. Phone/Fax

Practice location:
  • Phone: 973-633-1122
  • Fax: 973-832-7550
Mailing address:
  • Phone: 973-633-1122
  • Fax: 973-832-7550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF337677-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00405400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: