Basic Information
Provider Information | |||||||||
NPI: | 1487731139 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CZENIS | ||||||||
FirstName: | AMY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 876 WESTMINSTER DR | ||||||||
Address2: |   | ||||||||
City: | TOMS RIVER | ||||||||
State: | NJ | ||||||||
PostalCode: | 087534474 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7322880383 | ||||||||
FaxNumber: | 6092617199 | ||||||||
Practice Location | |||||||||
Address1: | 8025 BLACK HORSE PIKE STE 501 | ||||||||
Address2: |   | ||||||||
City: | PLEASANTVILLE | ||||||||
State: | NJ | ||||||||
PostalCode: | 082322967 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8449290225 | ||||||||
FaxNumber: | 6098227980 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2006 | ||||||||
LastUpdateDate: | 03/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 26NO09756900 | NJ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
ID | Type | State | Issuer | Description | 2196326000 | 01 |   | AMERIHEALTH/KEYSTONE/PC | OTHER | 500017915 | 01 | NJ | RAILROAD MEDICARE | OTHER |