Basic Information
| Provider Information | |||||||||
| NPI: | 1063879393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICH | ||||||||
| FirstName: | MARYRUTH | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOPRESTI | ||||||||
| OtherFirstName: | MARYRUTH | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 200 HYGEIA DR | ||||||||
| Address2: | CCHS PHYSICIAN CONTRACTING, SUITE 2300 | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 86 OMEGA DR | ||||||||
| Address2: | OMEGA PROFESSIONAL CENTER, BUILDING B-86 | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026231929 | ||||||||
| FaxNumber: | 3023661075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2016 | ||||||||
| LastUpdateDate: | 11/08/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | L1-0033156 | DE | N | Nursing Service Providers | Registered Nurse | 363LF0000X | LG-0000912 | DE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.