Provider Demographics
NPI:1689306433
Name:DOMENIC, MARYANNA VRETTOS
Entity Type:Individual
Prefix:
First Name:MARYANNA
Middle Name:VRETTOS
Last Name:DOMENIC
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 1:2 FARM RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07930-2821
Mailing Address - Country:US
Mailing Address - Phone:908-803-1779
Mailing Address - Fax:
Practice Address - Street 1:2 FARM RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NJ
Practice Address - Zip Code:07930-2821
Practice Address - Country:US
Practice Address - Phone:908-803-1779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR16641700163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse