Provider Demographics
NPI:1740347095
Name:WIGHT, MARY IZZO (PMHNP, RN, BSN, LAC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:IZZO
Last Name:WIGHT
Suffix:
Gender:F
Credentials:PMHNP, RN, BSN, LAC
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Mailing Address - Street 1:229 E 8TH ST # 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-3303
Mailing Address - Country:US
Mailing Address - Phone:718-483-5515
Mailing Address - Fax:
Practice Address - Street 1:1630 E 15TH ST FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1193
Practice Address - Country:US
Practice Address - Phone:646-477-3779
Practice Address - Fax:914-220-4231
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY664500163W00000X
NY25003048171100000X
NY403071363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No171100000XOther Service ProvidersAcupuncturist