Provider Demographics
NPI:1063848885
Name:AMISTOSO, GRACE (APN)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:AMISTOSO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LOCKBAG R
Mailing Address - Street 2:E JERSEY STATE PRISON ATTN MEDICAL DEPT
Mailing Address - City:RAHWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07106
Mailing Address - Country:US
Mailing Address - Phone:732-399-5010
Mailing Address - Fax:
Practice Address - Street 1:LOCK BAG & WOODBRIGE AVE
Practice Address - Street 2:E JERSEY STATE PRISON ATTN MEDICAL DEPT
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07067
Practice Address - Country:US
Practice Address - Phone:732-499-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NC06249800363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner