Provider Demographics
NPI:1750646824
Name:PORRETTA, MARY JANE (MS)
Entity Type:Individual
Prefix:MRS
First Name:MARY JANE
Middle Name:
Last Name:PORRETTA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 GARDEN RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-9666
Mailing Address - Country:US
Mailing Address - Phone:631-882-8834
Mailing Address - Fax:
Practice Address - Street 1:56 GARDEN RD
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-9666
Practice Address - Country:US
Practice Address - Phone:631-882-8834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist