Provider Demographics
NPI:1518152453
Name:MARCY ROSHELLI
Entity Type:Organization
Organization Name:MARCY ROSHELLI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSHELLI
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-BC
Authorized Official - Phone:609-312-9269
Mailing Address - Street 1:18 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SURF CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08008-5201
Mailing Address - Country:US
Mailing Address - Phone:609-312-9269
Mailing Address - Fax:609-207-4102
Practice Address - Street 1:1301 ROUTE 72 W
Practice Address - Street 2:SUITE 250
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2483
Practice Address - Country:US
Practice Address - Phone:609-312-9269
Practice Address - Fax:609-207-4102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN05675900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8092605Medicaid
S97095Medicare UPIN
NJ8092605Medicaid