Provider Demographics
NPI:1689306433
Name:DOMENIC, MARYANNA VRETTOS
Entity type:Individual
Prefix:
First Name:MARYANNA
Middle Name:VRETTOS
Last Name:DOMENIC
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 1:45 PERRY ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07930-3604
Mailing Address - Country:US
Mailing Address - Phone:908-315-9913
Mailing Address - Fax:
Practice Address - Street 1:45 PERRY ST UNIT 2
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NJ
Practice Address - Zip Code:07930-3604
Practice Address - Country:US
Practice Address - Phone:908-315-9913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR16641700163W00000X
NJ26NJ15070600363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse