Provider Demographics
NPI:1215707179
Name:GRESHAM, LA'NAE NA (FNP)
Entity type:Individual
Prefix:
First Name:LA'NAE
Middle Name:NA
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 BUFFETT TER
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-6027
Mailing Address - Country:US
Mailing Address - Phone:917-744-4052
Mailing Address - Fax:
Practice Address - Street 1:1485 BUFFETT TER
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-6027
Practice Address - Country:US
Practice Address - Phone:917-744-4052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF351612363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily