Healthcare Provider Details

I. General information

NPI: 1962521989
Provider Name (Legal Business Name): MARYELLEN MCKIE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27005 76TH AVE
NEW HYDE PARK NY
11040-1433
US

IV. Provider business mailing address

175 COMMUNITY DR
GREAT NECK NY
11021-5502
US

V. Phone/Fax

Practice location:
  • Phone: 516-465-1900
  • Fax: 516-465-1830
Mailing address:
  • Phone: 516-465-1900
  • Fax: 516-465-1830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number188384
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF303091
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: