Basic Information
| Provider Information | |||||||||
| NPI: | 1356989321 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | COURTNEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DANIELS | ||||||||
| OtherFirstName: | COURTNEY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 900 MEDICAL CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080802358 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 MEDICAL CENTER DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080802358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565577900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2019 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 26NJ01001600 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0715590 | 05 | NH | MEDICAID |