Healthcare Provider Details

I. General information

NPI: 1184179111
Provider Name (Legal Business Name): MARIA CIVILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4771 HYLAN BLVD
STATEN ISLAND NY
10312-6315
US

IV. Provider business mailing address

55 WATER ST 12TH FLOOR
NEW YORK NY
10041-0004
US

V. Phone/Fax

Practice location:
  • Phone: 718-948-8200
  • Fax:
Mailing address:
  • Phone: 646-680-2888
  • Fax: 516-542-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number340526
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: