Provider Demographics
NPI:1033530753
Name:RODRIGUEZ, MAYRA JOSELYN
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:JOSELYN
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAYRA
Other - Middle Name:JOSELYN
Other - Last Name:RAMIREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1 MAYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07607-1001
Mailing Address - Country:US
Mailing Address - Phone:201-464-4772
Mailing Address - Fax:
Practice Address - Street 1:7 MARTINDALE RD # 1
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-1614
Practice Address - Country:US
Practice Address - Phone:973-638-1107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-23
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00473100363L00000X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine