Basic Information
Provider Information | |||||||||
NPI: | 1164757118 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PUGH | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | RUTH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NURSE PRACTITIONER | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PUGH | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | RUTH | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4701 OGLETOWN-STANTON RD. | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | DE | ||||||||
PostalCode: | 19713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3023661200 | ||||||||
FaxNumber: | 3023661700 | ||||||||
Practice Location | |||||||||
Address1: | 4701 OGLETOWN-STANTON RD. | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | DE | ||||||||
PostalCode: | 19713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3023661200 | ||||||||
FaxNumber: | 3023661700 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/08/2009 | ||||||||
LastUpdateDate: | 10/08/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | LG-0000503 | DE | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.