Basic Information
| Provider Information | |||||||||
| NPI: | 1326089673 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DARVISH-MAHTABFAR | ||||||||
| FirstName: | MAHNAZ | ||||||||
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| Credential: | RN, MS, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 288 GREENRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN LAKES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074172012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008422478 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 PENN PLZ STE 725 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 101190002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008422478 | ||||||||
| FaxNumber: | 2122166606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 26NR10302000 | NJ | X | Nursing Service Providers | Registered Nurse | 363LF0000X | 26NJ00003300 | NJ | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0066427 | 05 | NJ | MEDICAID |