Provider Demographics
NPI:1548610546
Name:SUPERNAVAGE, WHITNEY (APN)
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:
Last Name:SUPERNAVAGE
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 1:42 DELSEA DR S
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-2621
Mailing Address - Country:US
Mailing Address - Phone:856-863-0006
Mailing Address - Fax:856-881-7614
Practice Address - Street 1:42 DELSEA DR S
Practice Address - Street 2:
Practice Address - City:GLASSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08028-2621
Practice Address - Country:US
Practice Address - Phone:856-863-0006
Practice Address - Fax:856-881-7614
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25NJ00645300363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health