Provider Demographics
NPI:1942027958
Name:DEGENNARO, SALVATORE JOSEPH (APRN)
Entity type:Individual
Prefix:
First Name:SALVATORE
Middle Name:JOSEPH
Last Name:DEGENNARO
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 LANCASTER RD
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-3111
Mailing Address - Country:US
Mailing Address - Phone:201-682-0515
Mailing Address - Fax:
Practice Address - Street 1:612 RUTHERFORD AVE # A
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:NJ
Practice Address - Zip Code:07071-1217
Practice Address - Country:US
Practice Address - Phone:201-682-0515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-21
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15205800363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner