Healthcare Provider Details

I. General information

NPI: 1871005611
Provider Name (Legal Business Name): CRYSTAL ANN MARQUES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 11/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23214 MERRICK BLVD
LAURELTON NY
11413-2115
US

IV. Provider business mailing address

145-40 GUY R BREWER BLVD
JAMAICA NY
11434
US

V. Phone/Fax

Practice location:
  • Phone: 718-528-3432
  • Fax:
Mailing address:
  • Phone: 239-645-5948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number740567
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: