=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356136709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER J MANNARI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2025
-----------------------------------------------------
Last Update Date | 04/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 58 N MAIN ST
-----------------------------------------------------
City | MARLBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07746-1451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-537-5242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 279 BAYVIEW AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10309-3628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-677-8649
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ15312200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------