Provider Demographics
NPI:1578926697
Name:OMOREGIE, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:OMOREGIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 WHITE HORSE AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08610-1410
Mailing Address - Country:US
Mailing Address - Phone:800-843-2220
Mailing Address - Fax:
Practice Address - Street 1:962 SHOPPES BLVD
Practice Address - Street 2:THE SHOPPES AT NORTH BRUNSWICK
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902
Practice Address - Country:US
Practice Address - Phone:800-843-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00626100363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology