Provider Demographics
NPI:1619993110
Name:TARGOVNIK, NAN (MA,CCC-A)
Entity Type:Individual
Prefix:
First Name:NAN
Middle Name:
Last Name:TARGOVNIK
Suffix:
Gender:F
Credentials:MA,CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O BOX 406153
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1876
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1455 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-2418
Practice Address - Country:US
Practice Address - Phone:732-549-7455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YA00015000231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7121105Medicaid
NJ093353Q6XMedicare PIN
NJ161755Q6XMedicare PIN