Provider Demographics
NPI:1124875158
Name:HERNANDEZ, NICOLE (MSN, CPNP-PC)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MSN, CPNP-PC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BACZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23-00 ROUTE 208 STE 1-5
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-1555
Mailing Address - Country:US
Mailing Address - Phone:201-797-1900
Mailing Address - Fax:
Practice Address - Street 1:23-00 ROUTE 208 STE 1-5
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-1555
Practice Address - Country:US
Practice Address - Phone:201-797-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01062400363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics