Healthcare Provider Details

I. General information

NPI: 1003670134
Provider Name (Legal Business Name): JOLLY ANN LAO MARQUEZ PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3227 E TREMONT AVE
BRONX NY
10461-5707
US

IV. Provider business mailing address

587 JAYNE BLVD
PORT JEFFERSON STATION NY
11776-2946
US

V. Phone/Fax

Practice location:
  • Phone: 718-691-6340
  • Fax:
Mailing address:
  • Phone: 347-755-3182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number051800-01
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: