Healthcare Provider Details

I. General information

NPI: 1902632474
Provider Name (Legal Business Name): TONYA CARMELL MARION RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 MADISON ST
SYRACUSE NY
13210-2319
US

IV. Provider business mailing address

86 FAIROAKS LN
BUFFALO NY
14227-1352
US

V. Phone/Fax

Practice location:
  • Phone: 315-426-3600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number835294
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: