Provider Demographics
NPI:1164562658
Name:GAGNON, DOREEN (APRN, BC)
Entity Type:Individual
Prefix:MRS
First Name:DOREEN
Middle Name:
Last Name:GAGNON
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2021
Mailing Address - Country:US
Mailing Address - Phone:973-667-4252
Mailing Address - Fax:973-374-3120
Practice Address - Street 1:297 16TH AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-1104
Practice Address - Country:US
Practice Address - Phone:973-374-3020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00076000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily