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General NPI Number Information
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NPI Number | 1053818559
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Entity Type | Individual
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Provider Name | CORINA M IANCULOVICI APRN, AG-PCP
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Gender | Female
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Dates
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Enumeration Date | 04/11/2018
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Last Update Date | 10/03/2018
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Provider Practice Location Address
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Address Line | 2640 HWY 70, BLDG.5 BUILDING #5, SUITE 102B
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City | MANASQUAN
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State | NJ
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Zip | 08736-9552
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Country | US
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Telephone | 732-292-0100
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Fax | 732-292-0900
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Provider Business Mailing Address
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Address Line | 2640 HWY 70, BLDG.5 BUILDING #5, SUITE 102B
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City | MANASQUAN
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State | NJ
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Zip | 08736-9552
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Country | US
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Telephone | 347-539-6369
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 26NJ00862000
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | 26NJ00862000
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License Number State | NJ
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