Healthcare Provider Details

I. General information

NPI: 1265395370
Provider Name (Legal Business Name): MARY MUNITZ MSN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

2405 KENSINGTON AVE
RICHMOND VA
23220-3415
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-2500
  • Fax:
Mailing address:
  • Phone: 210-414-2457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number35053
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: