Healthcare Provider Details

I. General information

NPI: 1538865779
Provider Name (Legal Business Name): MARY A WHITE CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 2ND ST
LAKEWOOD NJ
08701-3324
US

IV. Provider business mailing address

991 BEACH HAVEN WEST BLVD
MANAHAWKIN NJ
08050-3812
US

V. Phone/Fax

Practice location:
  • Phone: 732-363-6655
  • Fax:
Mailing address:
  • Phone: 732-266-3587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberNN78638
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: