Provider Demographics
NPI:1770946501
Name:PANAH, MINA
Entity type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:PANAH
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:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08404-1387
Mailing Address - Country:US
Mailing Address - Phone:609-340-8200
Mailing Address - Fax:609-340-8273
Practice Address - Street 1:8 N MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-4013
Practice Address - Country:US
Practice Address - Phone:609-340-8200
Practice Address - Fax:609-340-8273
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR18143000133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education