Healthcare Provider Details

I. General information

NPI: 1437578515
Provider Name (Legal Business Name): MARIANNA LUNDBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 CHEYENNE TRL
SPARTA NJ
07871-2925
US

IV. Provider business mailing address

81 CHEYENNE TRL
SPARTA NJ
07871-2925
US

V. Phone/Fax

Practice location:
  • Phone: 201-317-7414
  • Fax:
Mailing address:
  • Phone: 201-317-7414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number26NO11023300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: