Provider Demographics
NPI:1447710553
Name:NNANABU, LOUISMARIE BERNADINE SR
Entity type:Individual
Prefix:
First Name:LOUISMARIE
Middle Name:BERNADINE
Last Name:NNANABU
Suffix:SR
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-2161
Mailing Address - Country:US
Mailing Address - Phone:201-463-2684
Mailing Address - Fax:
Practice Address - Street 1:522 ORANGE ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-2161
Practice Address - Country:US
Practice Address - Phone:201-463-2684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-24
Last Update Date:2019-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00902200363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health