Provider Demographics
NPI:1245005669
Name:NISSI IV HYDRATION THERAPY AND WELLNESS CLINIC LLC
Entity type:Organization
Organization Name:NISSI IV HYDRATION THERAPY AND WELLNESS CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER,ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADIYIA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:732-301-4465
Mailing Address - Street 1:15 W PROSPECT STREET SUITE 3
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-8578
Mailing Address - Country:US
Mailing Address - Phone:732-301-4465
Mailing Address - Fax:
Practice Address - Street 1:15 W PROSPECT ST STE 3
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-2161
Practice Address - Country:US
Practice Address - Phone:732-301-4465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-15
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty