Provider Demographics
NPI:1194061879
Name:DE LUCIA ADVANCE PRACTICE
Entity type:Organization
Organization Name:DE LUCIA ADVANCE PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:DE LUCIA
Authorized Official - Suffix:
Authorized Official - Credentials:ACNP-BC
Authorized Official - Phone:201-854-1500
Mailing Address - Street 1:7617 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-4024
Mailing Address - Country:US
Mailing Address - Phone:201-854-1500
Mailing Address - Fax:201-854-1505
Practice Address - Street 1:7617 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-4024
Practice Address - Country:US
Practice Address - Phone:201-854-1500
Practice Address - Fax:201-854-1505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-27
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00060000363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJQ23636Medicare UPIN