Provider Demographics
NPI:1538865779
Name:WHITE, MARY A (CPNP-PC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:WHITE
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 BEACH HAVEN WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-3812
Mailing Address - Country:US
Mailing Address - Phone:732-266-3587
Mailing Address - Fax:
Practice Address - Street 1:101 2ND ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-3324
Practice Address - Country:US
Practice Address - Phone:732-363-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNN78638363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics