Healthcare Provider Details

I. General information

NPI: 1518890698
Provider Name (Legal Business Name): MADISON RAE FARR PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6686 FRESH POND RD
RIDGEWOOD NY
11385-3949
US

IV. Provider business mailing address

501 W 110TH ST APT 10F
NEW YORK NY
10025-2076
US

V. Phone/Fax

Practice location:
  • Phone: 718-576-3607
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number408610
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: