Healthcare Provider Details

I. General information

NPI: 1346626868
Provider Name (Legal Business Name): MARILYN VERNA RN, NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ROUTE 25A
SMITHTOWN NY
11787-1348
US

IV. Provider business mailing address

12 HAYWARD AVE
MILLER PLACE NY
11764-1817
US

V. Phone/Fax

Practice location:
  • Phone: 631-862-3000
  • Fax:
Mailing address:
  • Phone: 631-474-2104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number426320-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF420535-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: