Provider Demographics
NPI:1104210301
Name:LONGO, MARIANNE MARIE
Entity Type:Individual
Prefix:MRS
First Name:MARIANNE
Middle Name:MARIE
Last Name:LONGO
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 1:1200 E RIDGEWOOD AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3957
Mailing Address - Country:US
Mailing Address - Phone:201-670-8660
Mailing Address - Fax:201-670-6693
Practice Address - Street 1:1200 E RIDGEWOOD AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3957
Practice Address - Country:US
Practice Address - Phone:201-670-8660
Practice Address - Fax:201-670-6693
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-25
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00559700363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner