Healthcare Provider Details

I. General information

NPI: 1669723607
Provider Name (Legal Business Name): JENNIFER MARRIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER NATALI

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 COUNTY HIGHWAY 25
RICHFIELD SPRINGS NY
13439-4722
US

IV. Provider business mailing address

1040 COUNTY HIGHWAY 25
RICHFIELD SPRINGS NY
13439-4722
US

V. Phone/Fax

Practice location:
  • Phone: 315-858-5448
  • Fax:
Mailing address:
  • Phone: 315-858-5448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number310773-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: