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General NPI Number Information
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NPI Number | 1902252315
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Entity Type | Organization
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Legal Business Name | SIDWA ENTERPRISE II, LLC
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Dates
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Enumeration Date | 05/04/2016
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Last Update Date | 05/10/2016
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Provider Practice Location Address
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Address Line | 1043 MONTAUK DR
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City | FORKED RIVER
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State | NJ
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Zip | 08731-2004
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Country | US
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Telephone | 609-339-5667
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Fax | 888-836-3950
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Provider Business Mailing Address
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Address Line | 1043 MONTAUK DR
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City | FORKED RIVER
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State | NJ
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Zip | 08731-2004
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Country | US
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Telephone | 609-339-5667
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Fax | 888-836-3950
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Authorized Official
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Title or Position | PRESIDENT OWNER
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Name | VICKIE S SIDWA
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Credential | ANP
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Telephone | 609-339-5667
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 26NN10119300
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License Number State | NJ
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