Basic Information
Provider Information | |||||||||
NPI: | 1932411857 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BASENESE | ||||||||
FirstName: | ANITA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, NP, APN-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 223 N VAN DIEN AVE | ||||||||
Address2: |   | ||||||||
City: | RIDGEWOOD | ||||||||
State: | NJ | ||||||||
PostalCode: | 074502726 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2014478000 | ||||||||
FaxNumber: | 2014478014 | ||||||||
Practice Location | |||||||||
Address1: | 223 N VAN DIEN AVE | ||||||||
Address2: |   | ||||||||
City: | RIDGEWOOD | ||||||||
State: | NJ | ||||||||
PostalCode: | 074502726 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2014478000 | ||||||||
FaxNumber: | 2014478014 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2010 | ||||||||
LastUpdateDate: | 07/08/2010 | ||||||||
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 | 363L00000X | 26NJ00169700 | NJ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | F440016-1 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | 26NO0011435800 | NJ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | 545216-1 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.