Provider Demographics
NPI:1134738396
Name:MERENDA, AUDREY ALICIA (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:ALICIA
Last Name:MERENDA
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 BROAD ST STE 201B
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3061
Mailing Address - Country:US
Mailing Address - Phone:201-833-9500
Mailing Address - Fax:
Practice Address - Street 1:1255 BROAD ST STE 201B
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3061
Practice Address - Country:US
Practice Address - Phone:201-833-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025140363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant