Provider Demographics
NPI:1790056182
Name:BASIL, RENJINI RAJU
Entity Type:Individual
Prefix:MRS
First Name:RENJINI
Middle Name:RAJU
Last Name:BASIL
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 1:202 HOWARD DRIVE
Mailing Address - Street 2:APT # I
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621
Mailing Address - Country:US
Mailing Address - Phone:201-385-0538
Mailing Address - Fax:
Practice Address - Street 1:202 HOWARD DRIVE
Practice Address - Street 2:APT # I
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621
Practice Address - Country:US
Practice Address - Phone:201-385-0538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00360600363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily