Healthcare Provider Details

I. General information

NPI: 1538805759
Provider Name (Legal Business Name): MARISA PETAGNO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 05/10/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SOUTH BROADWAY 4TH FLOOR
WHITE PLAINS NY
10601
US

IV. Provider business mailing address

135 ORCHARD PARK
ALLENDALE NJ
07401
US

V. Phone/Fax

Practice location:
  • Phone: 914-293-5001
  • Fax:
Mailing address:
  • Phone: 201-316-3282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number738443
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: