Basic Information
Provider Information | |||||||||
NPI: | 1093795585 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VAN FOSSEN | ||||||||
FirstName: | ELLEN | ||||||||
MiddleName: | T | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, APN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DODDY | ||||||||
OtherFirstName: | ELLEN | ||||||||
OtherMiddleName: | T | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 42 E LAUREL RD | ||||||||
Address2: | UDP #1800 | ||||||||
City: | STRATFORD | ||||||||
State: | NJ | ||||||||
PostalCode: | 080841354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8565666843 | ||||||||
FaxNumber: | 8565666419 | ||||||||
Practice Location | |||||||||
Address1: | 42 LAUREL RD E | ||||||||
Address2: | UDP #1800 | ||||||||
City: | STRATFORD | ||||||||
State: | NJ | ||||||||
PostalCode: | 080841354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8565666843 | ||||||||
FaxNumber: | 8565666419 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2006 | ||||||||
LastUpdateDate: | 01/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | NO08244100 | NJ | N |   | Nursing Service Providers | Registered Nurse |   | 363LG0600X | NN08244100 | NJ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
ID | Type | State | Issuer | Description | 8132208 | 05 | NJ |   | MEDICAID |