Provider Demographics
NPI:1265593933
Name:ANGELICOLA, SUSAN A (MSN, RNC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:A
Last Name:ANGELICOLA
Suffix:
Gender:F
Credentials:MSN, RNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 W GILBERT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4947
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:890 MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:NEW PROVIDENCE
Practice Address - State:NJ
Practice Address - Zip Code:07974-1218
Practice Address - Country:US
Practice Address - Phone:908-277-8799
Practice Address - Fax:908-608-2376
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN11336200363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0052027Medicaid
NJ086810Medicare PIN
NJ0052027Medicaid
NJ151095A0WMedicare PIN