Provider Demographics
NPI:1629781000
Name:SACKOR, MARCONI CHU-CHU
Entity Type:Individual
Prefix:
First Name:MARCONI
Middle Name:CHU-CHU
Last Name:SACKOR
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 1:713 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08312-2131
Mailing Address - Country:US
Mailing Address - Phone:443-740-1672
Mailing Address - Fax:
Practice Address - Street 1:713 S BROAD ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NJ
Practice Address - Zip Code:08312-2131
Practice Address - Country:US
Practice Address - Phone:443-740-1672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01407100363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health