Provider Demographics
NPI:1356092480
Name:DORESTIL, MADELINE KAYLIE (APN)
Entity Type:Individual
Prefix:MISS
First Name:MADELINE
Middle Name:KAYLIE
Last Name:DORESTIL
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 1:234 GLOBE AVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-7242
Mailing Address - Country:US
Mailing Address - Phone:862-218-8245
Mailing Address - Fax:
Practice Address - Street 1:126 US HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-3175
Practice Address - Country:US
Practice Address - Phone:973-381-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01239300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily