Provider Demographics
NPI:1851998488
Name:MICHELETTE, KENNETH PAUL (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:PAUL
Last Name:MICHELETTE
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 ENGLISH CREEK AVE
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-5549
Mailing Address - Country:US
Mailing Address - Phone:609-407-2300
Mailing Address - Fax:
Practice Address - Street 1:72 W JIMMIE LEEDS RD STE 2500
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9413
Practice Address - Country:US
Practice Address - Phone:609-377-5133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01060700207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine