Provider Demographics
NPI:1891478962
Name:MAMREGA, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:MAMREGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PINE HILL ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-2414
Mailing Address - Country:US
Mailing Address - Phone:732-796-5495
Mailing Address - Fax:
Practice Address - Street 1:2 PINE HILL ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-2414
Practice Address - Country:US
Practice Address - Phone:732-796-5495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJM03735196258712172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver