Provider Demographics
NPI:1366479891
Name:HERRON, MARY A
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:HERRON
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 1:5511 PACIFIC AVE
Mailing Address - Street 2:C-204
Mailing Address - City:WILDWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08260-4360
Mailing Address - Country:US
Mailing Address - Phone:609-522-1555
Mailing Address - Fax:
Practice Address - Street 1:70 COHANSEY ST
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302
Practice Address - Country:US
Practice Address - Phone:856-451-4700
Practice Address - Fax:856-451-0029
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNN03109700164W00000X
NJ26NN03109700363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse