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General NPI Number Information
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NPI Number | 1366989881
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Entity Type | Organization
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Legal Business Name | MENTAL HEALTH NOURISHMENT
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Dates
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Enumeration Date | 01/22/2017
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Last Update Date | 04/20/2017
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Provider Practice Location Address
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Address Line | 81 2ND ST SUITE 8
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City | SOUTH ORANGE
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State | NJ
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Zip | 07079-1861
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Country | US
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Telephone | 862-283-7409
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Fax |
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Provider Business Mailing Address
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Address Line | 81 2ND ST SUITE 8
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City | SOUTH ORANGE
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State | NJ
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Zip | 07079-1861
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | APN
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Name | LISSA EDMOND
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Credential |
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Telephone | 862-283-7409
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 26NJ00627000
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License Number State | NJ
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