Provider Demographics
NPI:1891126173
Name:DE JESUS, MICHELLE RIVERA (APN)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RIVERA
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:DAJAY
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:140 FRANKLIN TURNPIKE
Mailing Address - Street 2:VM6
Mailing Address - City:WALDWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:07643
Mailing Address - Country:US
Mailing Address - Phone:201-447-3603
Mailing Address - Fax:201-447-5184
Practice Address - Street 1:140 FRANKLIN TURNPIKE
Practice Address - Street 2:VM6
Practice Address - City:WALDWICK
Practice Address - State:NJ
Practice Address - Zip Code:07643
Practice Address - Country:US
Practice Address - Phone:201-447-3603
Practice Address - Fax:201-447-5184
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00460700364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health