Provider Demographics
NPI:1124132816
Name:KOPAKOWSKI, MARY JANE
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JANE
Last Name:KOPAKOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JANE
Other - Last Name:APPLEBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:120 WHITE HORSE PIKE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:HADDON HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08035-1927
Mailing Address - Country:US
Mailing Address - Phone:856-546-3003
Mailing Address - Fax:856-547-3178
Practice Address - Street 1:210 W ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:HADDON HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08035-1715
Practice Address - Country:US
Practice Address - Phone:856-546-3003
Practice Address - Fax:856-547-3178
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00105300363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJQ67166Medicare UPIN
NJ099849BDGMedicare PIN