Provider Demographics
NPI:1386461952
Name:PROVENZANO, MARIA LILLIAN (FNP-BC)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:LILLIAN
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-2003
Mailing Address - Country:US
Mailing Address - Phone:732-842-3600
Mailing Address - Fax:732-383-6888
Practice Address - Street 1:282 BROAD ST
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-2003
Practice Address - Country:US
Practice Address - Phone:732-842-3600
Practice Address - Fax:732-383-6888
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR20988600163W00000X
NJ26NJ15197600363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse