Provider Demographics
NPI:1104841154
Name:BUCKHOLZ, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:BUCKHOLZ
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 1:24 BOOKER STREET
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-2619
Mailing Address - Country:US
Mailing Address - Phone:201-822-0100
Mailing Address - Fax:201-822-0107
Practice Address - Street 1:24 BOOKER STREET
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-2619
Practice Address - Country:US
Practice Address - Phone:201-822-0100
Practice Address - Fax:201-822-0107
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA00518500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7549915OtherAETNA ID #
NJ103238Medicare ID - Type UnspecifiedMEDICARE PROVIDER #