=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285416578
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL ROBERT FAWCETT NP STUDENT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2023
-----------------------------------------------------
Last Update Date | 08/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 S ORANGE AVE
-----------------------------------------------------
City | SOUTH ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07079-2697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-761-9000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1756 RICHMOND AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10314-3902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-477-5670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | F407438-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------