=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164655486
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRISTIN ASHLEY FAMULARO A.P.N
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2009
-----------------------------------------------------
Last Update Date | 11/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 LACKAWANNA PL 412
-----------------------------------------------------
City | BLOOMFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07003-2955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-913-7146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 465 BLOOMFIELD AVE
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-3548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-587-8040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ00201200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 26NJ00201200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------