Provider Demographics
NPI:1871219444
Name:VIVAR, BRENDA MICHELLE (APN)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:MICHELLE
Last Name:VIVAR
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 DATER ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HALEDON
Mailing Address - State:NJ
Mailing Address - Zip Code:07508-2520
Mailing Address - Country:US
Mailing Address - Phone:201-927-9021
Mailing Address - Fax:
Practice Address - Street 1:357 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-2519
Practice Address - Country:US
Practice Address - Phone:551-309-3555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01364900363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care