=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720135593
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JILL GUZMAN APN NURSE PRACTITION
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2007
-----------------------------------------------------
Last Update Date | 03/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5301 BROADWAY
-----------------------------------------------------
City | WEST NEW YORK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07093-2622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-866-9320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 206 ANDOVER DR
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470-2958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | NN111636
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------