Basic Information
| Provider Information | |||||||||
| NPI: | 1770067514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SACCO | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOLTON | ||||||||
| OtherFirstName: | KRISTINA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 151 FRIES MILL RD STE 301 | ||||||||
| Address2: | |||||||||
| City: | TURNERSVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080122016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565134124 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2201 CHAPEL AVE W | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080022048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564886500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2018 | ||||||||
| LastUpdateDate: | 02/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 26NJ00856900 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 0652181 | 05 | NJ | MEDICAID |