Provider Demographics
NPI:1417365776
Name:BALOGUN, NASHANDA (AGPCNP)
Entity type:Individual
Prefix:
First Name:NASHANDA
Middle Name:
Last Name:BALOGUN
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 VALLEY RD # 148
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2709
Mailing Address - Country:US
Mailing Address - Phone:973-559-4600
Mailing Address - Fax:855-998-4358
Practice Address - Street 1:28 VALLEY RD # 148
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2709
Practice Address - Country:US
Practice Address - Phone:973-559-4600
Practice Address - Fax:855-998-4358
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-30
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013879363LA2200X, 363LP2300X
NJ26NJ15053300363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care