Healthcare Provider Details

I. General information

NPI: 1972743698
Provider Name (Legal Business Name): ANGELITO ANTONIO NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2009
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 VALLEY RD
WAYNE NJ
07470
US

IV. Provider business mailing address

930 VALLEY RD
WAYNE NJ
07470-2900
US

V. Phone/Fax

Practice location:
  • Phone: 973-696-3868
  • Fax:
Mailing address:
  • Phone: 973-696-3868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number26NJ00260500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberF305268-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberF340760-1
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number26NJ00260500
License Number StateNJ
# 5
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number26NJ00260500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: