Provider Demographics
NPI:1518735745
Name:MACCARONE, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:MACCARONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GRENLOCH
Mailing Address - State:NJ
Mailing Address - Zip Code:08032-9015
Mailing Address - Country:US
Mailing Address - Phone:609-922-6209
Mailing Address - Fax:
Practice Address - Street 1:109 LAKE AVE
Practice Address - Street 2:
Practice Address - City:GRENLOCH
Practice Address - State:NJ
Practice Address - Zip Code:08032-9015
Practice Address - Country:US
Practice Address - Phone:609-922-6209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer