Provider Demographics
NPI:1538262704
Name:HALLECK, LOIS R (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:LOIS
Middle Name:R
Last Name:HALLECK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:141 S BLACK HORSE PIKE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2975
Mailing Address - Country:US
Mailing Address - Phone:856-292-8216
Mailing Address - Fax:856-848-3011
Practice Address - Street 1:141 S BLACK HORSE PIKE
Practice Address - Street 2:SUITE 104
Practice Address - City:BLACKWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08012-2975
Practice Address - Country:US
Practice Address - Phone:856-292-8216
Practice Address - Fax:856-848-3011
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR05584600207Q00000X
NJ26NJ00003800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00037276Medicare ID - Type Unspecified
P68045Medicare UPIN