Provider Demographics
NPI:1588857130
Name:DELISSER, OPAL M (APN-C)
Entity Type:Individual
Prefix:
First Name:OPAL
Middle Name:M
Last Name:DELISSER
Suffix:
Gender:F
Credentials:APN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FEDERAL ST
Mailing Address - Street 2:STE SW200
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1155
Mailing Address - Country:US
Mailing Address - Phone:856-342-2604
Mailing Address - Fax:856-968-8282
Practice Address - Street 1:3 COOPER PLZ
Practice Address - Street 2:SUITE 311
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1438
Practice Address - Country:US
Practice Address - Phone:856-342-2034
Practice Address - Fax:856-342-6608
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNR07295200363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJNR07295200OtherNJ MEDICAL LICENSE