Provider Demographics
NPI:1205905809
Name:NINIVAGGI, LORETTA M (RN, APN,C CDE)
Entity type:Individual
Prefix:
First Name:LORETTA
Middle Name:M
Last Name:NINIVAGGI
Suffix:
Gender:F
Credentials:RN, APN,C CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 STATE ROUTE 33
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-6110
Mailing Address - Country:US
Mailing Address - Phone:732-897-3980
Mailing Address - Fax:732-897-3982
Practice Address - Street 1:2240 STATE ROUTE 33
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-6110
Practice Address - Country:US
Practice Address - Phone:732-897-3980
Practice Address - Fax:732-897-3982
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00067000363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ123096UWDMedicare PIN