Healthcare Provider Details

I. General information

NPI: 1790843548
Provider Name (Legal Business Name): MARCIA BRADY LOUGHRAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31-51 STONEY ST. PHEONIX HOUSE
SHRUB OAK NY
10058
US

IV. Provider business mailing address

2168 19TH ST APT 1
ASTORIA NY
11105-3933
US

V. Phone/Fax

Practice location:
  • Phone: 914-962-2491
  • Fax:
Mailing address:
  • Phone: 718-267-7174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF332129-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: