Basic Information
| Provider Information | |||||||||
| NPI: | 1538115084 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VETTER | ||||||||
| FirstName: | MARY JO | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | RN , APRN, CS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 729 | ||||||||
| Address2: | |||||||||
| City: | TENAFLY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076700729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2013323354 | ||||||||
| FaxNumber: | 2015369047 | ||||||||
| Practice Location | |||||||||
| Address1: | 196 JEWETT AVE | ||||||||
| Address2: | |||||||||
| City: | JERSEY CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 073041804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2013323354 | ||||||||
| FaxNumber: | 2015369047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0600X | NJ | X | Nursing Service Providers | Registered Nurse | Gerontology | 363LA2200X | NJ | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 7414404 | 05 | NJ | MEDICAID |