Provider Demographics
NPI:1356995245
Name:DIRIENZO, NICOLE MARIE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:MARIE
Last Name:DIRIENZO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 JAYMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-2878
Mailing Address - Country:US
Mailing Address - Phone:302-753-2850
Mailing Address - Fax:
Practice Address - Street 1:3926 KIRKWOOD HWY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5110
Practice Address - Country:US
Practice Address - Phone:302-998-2417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0001326363A00000X, 363AM0700X
NJ25MP00536300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant