Provider Demographics
NPI:1619558822
Name:JOSE, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JOSE
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 1:45 BAY HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-4515
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1199 PLEASANT VALLEY WAY
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1424
Practice Address - Country:US
Practice Address - Phone:973-731-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01989000208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation