Provider Demographics
NPI:1053818559
Name:IANCULOVICI, CORINA M (APRN, AG-PCP)
Entity Type:Individual
Prefix:
First Name:CORINA
Middle Name:M
Last Name:IANCULOVICI
Suffix:
Gender:F
Credentials:APRN, AG-PCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 HWY 70, BLDG.5
Mailing Address - Street 2:BUILDING #5, SUITE 102B
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-9552
Mailing Address - Country:US
Mailing Address - Phone:347-539-6369
Mailing Address - Fax:
Practice Address - Street 1:2640 HWY 70, BLDG.5
Practice Address - Street 2:BUILDING #5, SUITE 102B
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-9552
Practice Address - Country:US
Practice Address - Phone:732-292-0100
Practice Address - Fax:732-292-0900
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00862000363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology