Provider Demographics
NPI:1023614658
Name:GROSSBARD, NICOLE LOREN (FNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LOREN
Last Name:GROSSBARD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 BROWNSTONE WAY APT 209
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-1211
Mailing Address - Country:US
Mailing Address - Phone:845-558-7229
Mailing Address - Fax:
Practice Address - Street 1:63 GRAND AVE STE 137
Practice Address - Street 2:
Practice Address - City:RIVER EDGE
Practice Address - State:NJ
Practice Address - Zip Code:07661-1930
Practice Address - Country:US
Practice Address - Phone:201-696-2646
Practice Address - Fax:201-485-6570
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY717409163WN0002X
NJ26NR22658200363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care