Provider Demographics
NPI:1699352567
Name:AUGUSTE, VICKYANA
Entity Type:Individual
Prefix:
First Name:VICKYANA
Middle Name:
Last Name:AUGUSTE
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 1:101 CONKLINTOWN RD
Mailing Address - Street 2:
Mailing Address - City:WANAQUE
Mailing Address - State:NJ
Mailing Address - Zip Code:07465-1605
Mailing Address - Country:US
Mailing Address - Phone:862-253-6355
Mailing Address - Fax:
Practice Address - Street 1:10 2ND AVE
Practice Address - Street 2:
Practice Address - City:HASKELL
Practice Address - State:NJ
Practice Address - Zip Code:07420-1109
Practice Address - Country:US
Practice Address - Phone:917-683-4658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP07836400164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26NP07836400Medicaid