Provider Demographics
NPI:1760457774
Name:MENNIE, ROBERTA F (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:F
Last Name:MENNIE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5227
Mailing Address - Country:US
Mailing Address - Phone:732-886-9101
Mailing Address - Fax:732-886-9523
Practice Address - Street 1:22 JENNIFER DR
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:NJ
Practice Address - Zip Code:07731-2367
Practice Address - Country:US
Practice Address - Phone:732-367-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00057700363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0062472Medicaid
NJQ28349Medicare UPIN
NJ085189Medicare ID - Type Unspecified