Provider Demographics
NPI:1962121251
Name:PROCTOR, KATHY ELLARENE NOVELLA (MS, BSN, RN- CCM)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:ELLARENE NOVELLA
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:MS, BSN, RN- CCM
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Other - Middle Name:
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Mailing Address - Street 1:182 E LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:DUMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:07628-1916
Mailing Address - Country:US
Mailing Address - Phone:646-401-3115
Mailing Address - Fax:201-330-4645
Practice Address - Street 1:182 E LINDEN AVE
Practice Address - Street 2:
Practice Address - City:DUMONT
Practice Address - State:NJ
Practice Address - Zip Code:07628-1916
Practice Address - Country:US
Practice Address - Phone:646-401-3115
Practice Address - Fax:201-330-4645
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ26NR22095100163WC0400X
NY543566163WC0400X
390200000X, 133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program