=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164562658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOREEN GAGNON APRN, BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 297 16TH AVE
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07103-1104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-374-3020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 42 HIGHLAND AVE
-----------------------------------------------------
City | NUTLEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07110-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-667-4252
-----------------------------------------------------
Fax | 973-374-3120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ00076000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------