Basic Information
| Provider Information | |||||||||
| NPI: | 1629201041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDEN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | Y. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOORE | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | YVONNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 68 S SERVICE RD | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117472358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453000 | ||||||||
| FaxNumber: | 5169453131 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 WOODSTOWN RD | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080792080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8569351000 | ||||||||
| FaxNumber: | 8569354757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2009 | ||||||||
| LastUpdateDate: | 03/24/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 26NJ00317500 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | L6-0A00585 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | L1-0030091 | DE | N | Nursing Service Providers | Registered Nurse | 163W00000X | 26NR10315300 | NJ | N | Nursing Service Providers | Registered Nurse | 367500000X | RN582566 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 82592 | 01 | AANA | OTHER | P01201184 | 01 | NJ | RAILROAD MEDICARE | OTHER |