Healthcare Provider Details

I. General information

NPI: 1427509843
Provider Name (Legal Business Name): MARTHA GEORGE MARCELLUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARTHA GEORGE JOSEPH

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 NEW YORK AVE
FREEPORT NY
11520-1538
US

IV. Provider business mailing address

134 NEW YORK AVE
FREEPORT NY
11520-1538
US

V. Phone/Fax

Practice location:
  • Phone: 646-416-3820
  • Fax:
Mailing address:
  • Phone: 646-416-3820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number623837-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number623837-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number623837-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: