Provider Demographics
NPI:1801069521
Name:VALES-BUCKWALD, NICOLE FABICO (CPNP)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:FABICO
Last Name:VALES-BUCKWALD
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:VALES
Other - Last Name:BUCKWALD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPNP
Mailing Address - Street 1:12 MATTBEN DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-7142
Mailing Address - Country:US
Mailing Address - Phone:908-420-0528
Mailing Address - Fax:
Practice Address - Street 1:5301 BROADWAY
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-2622
Practice Address - Country:US
Practice Address - Phone:201-866-9320
Practice Address - Fax:201-866-7588
Is Sole Proprietor?:No
Enumeration Date:2008-04-03
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN08808600363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26NN08808600OtherNJ APRN LICENSE