Healthcare Provider Details

I. General information

NPI: 1407770779
Provider Name (Legal Business Name): GENESIS MARINA ZAVALA LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 AVENUE U
BROOKLYN NY
11223-5019
US

IV. Provider business mailing address

14 PINELAWN AVE
SHIRLEY NY
11967-2020
US

V. Phone/Fax

Practice location:
  • Phone: 718-717-8337
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number356302
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: