Provider Demographics
NPI:1790765444
Name:REILLY, NANCY J (NP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:J
Last Name:REILLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 513
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08754-0513
Mailing Address - Country:US
Mailing Address - Phone:732-244-9068
Mailing Address - Fax:732-341-5644
Practice Address - Street 1:9 MULE RD
Practice Address - Street 2:SUITE E-6
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-5043
Practice Address - Country:US
Practice Address - Phone:732-244-9068
Practice Address - Fax:732-341-5644
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN07347000363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJR96664Medicare UPIN
NJ696026PADMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER