Basic Information
| Provider Information | |||||||||
| NPI: | 1316255979 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VASOLD | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BANACH | ||||||||
| OtherFirstName: | CAROL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4979 | ||||||||
| Address2: | |||||||||
| City: | TOMS RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087544979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322444700 | ||||||||
| FaxNumber: | 7322448482 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 W WATER ST | ||||||||
| Address2: | |||||||||
| City: | TOMS RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087536407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322444700 | ||||||||
| FaxNumber: | 7322448482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2010 | ||||||||
| LastUpdateDate: | 06/06/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP012103 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | RN575054 | PA | N | Nursing Service Providers | Registered Nurse | 163W00000X | 26NR13660700 | NJ | N | Nursing Service Providers | Registered Nurse | 363LA2200X | SP010720 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | 26NJ00376100 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.