Healthcare Provider Details

I. General information

NPI: 1598791444
Provider Name (Legal Business Name): MARY PATRICIA BREITWIESER C.N.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PROSPECT ST SUITE 202
LAKEWOOD NJ
08701-5020
US

IV. Provider business mailing address

321 EMBERLY RD
BRICK NJ
08723-6428
US

V. Phone/Fax

Practice location:
  • Phone: 732-942-4442
  • Fax:
Mailing address:
  • Phone: 732-920-8051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberME000014
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: