Basic Information
Provider Information | |||||||||
NPI: | 1730649138 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRISSETT | ||||||||
FirstName: | STACY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1445 WHITEHORSE MERCERVILLE RD STE 111 | ||||||||
Address2: |   | ||||||||
City: | HAMILTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 086193834 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6096895725 | ||||||||
FaxNumber: | 6096895726 | ||||||||
Practice Location | |||||||||
Address1: | 100 K JOHNSON BLVD | ||||||||
Address2: |   | ||||||||
City: | BORDENTOWN | ||||||||
State: | NJ | ||||||||
PostalCode: | 085052275 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6096895725 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2019 | ||||||||
LastUpdateDate: | 04/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 26NO11219900 | NJ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.