Provider Demographics
NPI:1376965616
Name:CRESPO, MAYRA (APN)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:CRESPO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:MAYRA
Other - Middle Name:
Other - Last Name:CHICAIZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:1680 ROUTE 23 STE 120
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-7520
Mailing Address - Country:US
Mailing Address - Phone:973-305-1400
Mailing Address - Fax:
Practice Address - Street 1:1680 RTE 23
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-7501
Practice Address - Country:US
Practice Address - Phone:973-305-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-06
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00478800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily