Healthcare Provider Details

I. General information

NPI: 1922791599
Provider Name (Legal Business Name): MARTHA Y GUARDIA APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 HAMBURG TPKE STE 207
WAYNE NJ
07470-2160
US

IV. Provider business mailing address

29 WEST ST
ELMWOOD PARK NJ
07407-2142
US

V. Phone/Fax

Practice location:
  • Phone: 973-653-3365
  • Fax:
Mailing address:
  • Phone: 908-340-7171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ01474700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number26NJ01474700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: