Healthcare Provider Details

I. General information

NPI: 1659784247
Provider Name (Legal Business Name): MARY NAKHLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 FROM RD STE 420
PARAMUS NJ
07652-3551
US

IV. Provider business mailing address

3600 ROUTE 66 FL 3
NEPTUNE NJ
07753-2645
US

V. Phone/Fax

Practice location:
  • Phone: 201-639-6620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number289743
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA10181000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: