Provider Demographics
NPI:1154751162
Name:PEGOLLO, SHIRLEY LACADEN (APN)
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:LACADEN
Last Name:PEGOLLO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 HIGH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-9604
Mailing Address - Country:US
Mailing Address - Phone:973-756-1504
Mailing Address - Fax:973-940-1045
Practice Address - Street 1:9 PONDEROSA TRL
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-3229
Practice Address - Country:US
Practice Address - Phone:973-768-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00444200363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health