=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508205550
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANYA M MARR FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2013
-----------------------------------------------------
Last Update Date | 06/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 807 NEWELL ST
-----------------------------------------------------
City | UTICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13502-5313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-798-9300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 LAUREL LN
-----------------------------------------------------
City | WHITESBORO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13492-2118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-525-3915
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F338076-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------