Healthcare Provider Details

I. General information

NPI: 1861085334
Provider Name (Legal Business Name): MARLENE DAMIAN A-GACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2021
Last Update Date: 02/16/2021
Certification Date: 01/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

967 N BROADWAY
YONKERS NY
10701-1301
US

IV. Provider business mailing address

506 N HIGH ST
MOUNT VERNON NY
10552-3105
US

V. Phone/Fax

Practice location:
  • Phone: 914-964-4444
  • Fax:
Mailing address:
  • Phone: 914-513-1281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number431938
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number431938
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number431938
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number431938
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: