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General NPI Number Information
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NPI Number | 1417201021
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Entity Type | Individual
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Provider Name | MARIA JOSE VASENA MARENGO #39
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Gender | Female
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Dates
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Enumeration Date | 11/04/2012
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Last Update Date | 08/03/2015
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Provider Practice Location Address
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Address Line | 330 LAFAYETTE AVE
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City | HAWTHORNE
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State | NJ
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Zip | 07506-2506
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Country | US
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Telephone | 973-841-5112
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Fax | 973-826-5064
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Provider Business Mailing Address
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Address Line | 18 MAPLE AVE
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City | MAHWAH
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State | NJ
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Zip | 07430-1233
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Country | US
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Telephone | 201-529-1595
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Fax | 973-826-5064
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 25MA09694700
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License Number State | NJ
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