Provider Demographics
NPI:1598032427
Name:CALLEJA, MA SOCORRO BERSOSA (LPN)
Entity Type:Individual
Prefix:MISS
First Name:MA SOCORRO
Middle Name:BERSOSA
Last Name:CALLEJA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:MA SOCORRO
Other - Middle Name:BERSOSA
Other - Last Name:CALLEJA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BSN, LPN
Mailing Address - Street 1:345 PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:RAHWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07065-1607
Mailing Address - Country:US
Mailing Address - Phone:347-283-8269
Mailing Address - Fax:
Practice Address - Street 1:345 PRINCETON AVENUE
Practice Address - Street 2:
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065
Practice Address - Country:US
Practice Address - Phone:347-283-8269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY666642-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQD12295MMedicaid