Healthcare Provider Details

I. General information

NPI: 1982174496
Provider Name (Legal Business Name): MARIAN FIONA MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5676 RIVERDALE AVE STE 202
BRONX NY
10471-2100
US

IV. Provider business mailing address

6300 RIVERDALE AVE APT 2H
BRONX NY
10471-1034
US

V. Phone/Fax

Practice location:
  • Phone: 718-796-5300
  • Fax:
Mailing address:
  • Phone: 646-228-8727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number539917-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: