Provider Demographics
NPI:1558516260
Name:NURSE PRACTITIONER PROFESSIONAL RESOURCES
Entity Type:Organization
Organization Name:NURSE PRACTITIONER PROFESSIONAL RESOURCES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MESHELL
Authorized Official - Middle Name:GLASGOW
Authorized Official - Last Name:MANSOR
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:856-885-4579
Mailing Address - Street 1:202 CABOT CT
Mailing Address - Street 2:
Mailing Address - City:DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-5114
Mailing Address - Country:US
Mailing Address - Phone:856-669-8488
Mailing Address - Fax:856-513-1377
Practice Address - Street 1:4361 ROUTE 42
Practice Address - Street 2:
Practice Address - City:BLACKWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08012-1794
Practice Address - Country:US
Practice Address - Phone:856-885-4579
Practice Address - Fax:856-728-3513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00097200363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty