Basic Information
| Provider Information | |||||||||
| NPI: | 1700236189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JULIANNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MONGAN | ||||||||
| OtherFirstName: | JULIANNE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 STATE ROUTE 31 | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | FLEMINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088225812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9087825100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 121 ROUTE 31 STE 1000 | ||||||||
| Address2: | |||||||||
| City: | FLEMINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088225755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082377018 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2016 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 26NJ00642400 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.