Healthcare Provider Details

I. General information

NPI: 1588105910
Provider Name (Legal Business Name): ROBERT MMEREOLE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2017
Last Update Date: 03/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 KENNEDY BLVD E SUITE 1
WEST NEW YORK NJ
07093-3902
US

IV. Provider business mailing address

6101 KENNEDY BLVD E
WEST NEW YORK NJ
07093-3902
US

V. Phone/Fax

Practice location:
  • Phone: 714-366-2581
  • Fax:
Mailing address:
  • Phone: 714-366-2581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA09692300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number26NJ00504700
License Number StateNJ

VIII. Authorized Official

Name: MRS. PAULINA MMEREOLE
Title or Position: NURSE PRACTITIONER
Credential: M.S.N.
Phone: 714-366-2581