Provider Demographics
NPI:1003241498
Name:ANSELMO, KHALENA F
Entity Type:Individual
Prefix:
First Name:KHALENA
Middle Name:F
Last Name:ANSELMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 HIGHWAY 71 STE 2
Mailing Address - Street 2:
Mailing Address - City:SEA GIRT
Mailing Address - State:NJ
Mailing Address - Zip Code:08750-2805
Mailing Address - Country:US
Mailing Address - Phone:732-974-8100
Mailing Address - Fax:
Practice Address - Street 1:700 HIGHWAY 71 STE 2
Practice Address - Street 2:
Practice Address - City:SEA GIRT
Practice Address - State:NJ
Practice Address - Zip Code:08750-2805
Practice Address - Country:US
Practice Address - Phone:732-974-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00460300363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner