Provider Demographics
NPI:1184792855
Name:WILLARD, REGINA (APN)
Entity type:Individual
Prefix:DR
First Name:REGINA
Middle Name:
Last Name:WILLARD
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 LAWRENCE RD
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-3100
Mailing Address - Country:US
Mailing Address - Phone:201-704-3486
Mailing Address - Fax:
Practice Address - Street 1:313 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:FANWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07023-1364
Practice Address - Country:US
Practice Address - Phone:908-889-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00139500363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
107837Medicare PIN
Q75925Medicare UPIN