Healthcare Provider Details

I. General information

NPI: 1407604358
Provider Name (Legal Business Name): MARYBETH JURICEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7164 168TH ST
FLUSHING NY
11365-3242
US

IV. Provider business mailing address

622 3RD AVE
NEW YORK NY
10017-6707
US

V. Phone/Fax

Practice location:
  • Phone: 718-591-1000
  • Fax: 718-591-8100
Mailing address:
  • Phone: 212-490-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number327227-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: