=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437538279
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIKOLETTA PROUDAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2015
-----------------------------------------------------
Last Update Date | 12/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 435 SOUTH ST STE 340
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07960-6473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-971-4599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 416457 STE 333
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02241-6457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-362-1735
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 5101025518
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------