Healthcare Provider Details

I. General information

NPI: 1336917822
Provider Name (Legal Business Name): KATY MIERTA APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2023
Last Update Date: 12/14/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 POMPTON RD
WAYNE NJ
07470-2103
US

IV. Provider business mailing address

123 SANDRA PL
BRICK NJ
08724-7041
US

V. Phone/Fax

Practice location:
  • Phone: 732-840-3537
  • Fax:
Mailing address:
  • Phone: 732-840-3537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ14973700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: