Provider Demographics
NPI:1487691523
Name:PENTRELLI DERACO, NICOLINA (LPT)
Entity type:Individual
Prefix:
First Name:NICOLINA
Middle Name:
Last Name:PENTRELLI DERACO
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:MISS
Other - First Name:NICOLINA
Other - Middle Name:
Other - Last Name:PENTRELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPT
Mailing Address - Street 1:11 EAGLE ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:EAST HANOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07936-3167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 EAGLE ROCK AVE
Practice Address - Street 2:
Practice Address - City:EAST HANOVER
Practice Address - State:NJ
Practice Address - Zip Code:07936-3167
Practice Address - Country:US
Practice Address - Phone:197-388-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022136-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQNO911Medicare PIN