Provider Demographics
NPI:1669860946
Name:VERGARA, LOURDES
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:VERGARA
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 1:420 DANIEL DR
Mailing Address - Street 2:
Mailing Address - City:STEWARTSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08886-3204
Mailing Address - Country:US
Mailing Address - Phone:908-337-1005
Mailing Address - Fax:908-454-8914
Practice Address - Street 1:420 DANIEL DR
Practice Address - Street 2:
Practice Address - City:STEWARTSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08886-3204
Practice Address - Country:US
Practice Address - Phone:908-337-1005
Practice Address - Fax:908-454-8914
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00535000363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health