Healthcare Provider Details

I. General information

NPI: 1013119973
Provider Name (Legal Business Name): MARIE ANN ADDESA APN, D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

647 MAIN AVE STE 202
PASSAIC NJ
07055-4962
US

IV. Provider business mailing address

647 MAIN AVE STE 202
PASSAIC NJ
07055-4962
US

V. Phone/Fax

Practice location:
  • Phone: 973-778-2300
  • Fax:
Mailing address:
  • Phone: 973-778-2300
  • Fax: 973-778-2311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number350691
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11027588
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ14914900
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number38MC00467000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: