=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619958659
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETTY A DITILLO APN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2005
-----------------------------------------------------
Last Update Date | 01/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 349 E NORTHFIELD RD
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07039-4806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-597-0900
-----------------------------------------------------
Fax | 973-597-0910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 415 JACK MARTIN BLVD
-----------------------------------------------------
City | BRICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08724-7732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-206-0800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 26NN07618800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------