Basic Information
| Provider Information | |||||||||
| NPI: | 1265699524 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN OCEAN REGISTERED NURSE FIRST ASSISTANT (RNFA),LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 PETER RD | ||||||||
| Address2: | |||||||||
| City: | MANAHAWKIN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080503659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095974603 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 PETER RD | ||||||||
| Address2: | |||||||||
| City: | MANAHAWKIN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080503659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6095974603 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2008 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | MILLIGAN | ||||||||
| AuthorizedOfficialFirstName: | DIANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6095974603 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | ARNP/C;RNFA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 26NJ00009800 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | ARNP2016122 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 163WR0006X | 26N005034800 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
ID Information
| ID | Type | State | Issuer | Description | 054778ATW | 01 | NJ | MEDICARE ID-TYPE UNSPECIFIED | OTHER | 0046655 | 05 | NJ | MEDICAID |