Provider Demographics
NPI:1952897829
Name:CIVICHAN, JANCY
Entity Type:Individual
Prefix:
First Name:JANCY
Middle Name:
Last Name:CIVICHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 N NEW RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08232-2170
Mailing Address - Country:US
Mailing Address - Phone:732-743-5910
Mailing Address - Fax:732-994-6993
Practice Address - Street 1:258 N NEW RD
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08232
Practice Address - Country:US
Practice Address - Phone:732-743-5910
Practice Address - Fax:732-994-6993
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-03
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00812700163WG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26NJ00812700OtherSTATE LICENSE