Provider Demographics
NPI:1194845925
Name:TARGOSZ, MARY (CNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:TARGOSZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2561 ELIZABETH LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-3313
Mailing Address - Country:US
Mailing Address - Phone:248-682-3300
Mailing Address - Fax:248-682-0026
Practice Address - Street 1:2561 ELIZABETH LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3313
Practice Address - Country:US
Practice Address - Phone:248-682-3300
Practice Address - Fax:248-682-0026
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704128135363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics