Provider Demographics
NPI:1942960919
Name:REVEN, MARY JOANNE (APN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JOANNE
Last Name:REVEN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 BRADFORD DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-2710
Mailing Address - Country:US
Mailing Address - Phone:609-257-7313
Mailing Address - Fax:
Practice Address - Street 1:1070 BRADFORD DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-2710
Practice Address - Country:US
Practice Address - Phone:609-257-7313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01199000363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care