Healthcare Provider Details

I. General information

NPI: 1265992416
Provider Name (Legal Business Name): MRS. MARY ELIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 BERGEN ST
NEWARK NJ
07103-2425
US

IV. Provider business mailing address

140 BERGEN ST
NEWARK NJ
07103-2425
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-2479
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NR13849900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: