Provider Demographics
NPI:1053700120
Name:MARINO, AMANDA SUE (CRNP)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:SUE
Last Name:MARINO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 COVENTRY DR
Mailing Address - Street 2:
Mailing Address - City:PHILLIPSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08865-1972
Mailing Address - Country:US
Mailing Address - Phone:908-454-4666
Mailing Address - Fax:908-454-2332
Practice Address - Street 1:700 COVENTRY DR
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-1972
Practice Address - Country:US
Practice Address - Phone:908-454-4666
Practice Address - Fax:908-454-2332
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP012936363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0495492Medicaid
NJ396755ZCJEMedicare PIN