Provider Demographics
NPI:1457185654
Name:FEARON, RECISA DALE (APN)
Entity type:Individual
Prefix:MISS
First Name:RECISA
Middle Name:DALE
Last Name:FEARON
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 1:23 ARCH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-4606
Mailing Address - Country:US
Mailing Address - Phone:973-580-4690
Mailing Address - Fax:
Practice Address - Street 1:29 E 29TH ST
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-4654
Practice Address - Country:US
Practice Address - Phone:201-858-5232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310202363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health