Healthcare Provider Details

I. General information

NPI: 1811201411
Provider Name (Legal Business Name): MARY BLESZCZ-MARMORATO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 03/07/2023
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 SEA MOUNTAIN HWY STE B
LITTLE RIVER SC
29566-8161
US

IV. Provider business mailing address

3600 SEA MOUNTAIN HWY STE B
LITTLE RIVER SC
29566-8161
US

V. Phone/Fax

Practice location:
  • Phone: 843-399-9696
  • Fax:
Mailing address:
  • Phone: 843-399-9696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number336441
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: