Provider Demographics
NPI:1154784734
Name:BACCHUS, REGINA
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:BACCHUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 BROOKSIDE RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08510-1235
Mailing Address - Country:US
Mailing Address - Phone:732-308-3499
Mailing Address - Fax:
Practice Address - Street 1:10 NATHAN D PERLMAN PLACE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:212-844-1871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY433362163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency