Healthcare Provider Details

I. General information

NPI: 1073319612
Provider Name (Legal Business Name): MARY PERMIAKOV APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY MARKOVIC

II. Dates (important events)

Enumeration Date: 02/24/2025
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JAMES ST FL 3
EDISON NJ
08820-3938
US

IV. Provider business mailing address

331 NEWMAN SPRINGS RD, BLDG 2, STE 220
RED BANK NJ
07701-5688
US

V. Phone/Fax

Practice location:
  • Phone: 732-202-8071
  • Fax:
Mailing address:
  • Phone: 917-940-0151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11037908
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: