MEDICARE: MADISON RAE FARR PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	408610	NY

General Provider Information

NPI Number	:	1518890698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON RAE FARR PMHNP

Provider Business Mailing Address
First Line	:	501 W 110TH ST APT 10F
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10025-2076
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6686 FRESH POND RD
Second Line	:
City	:	RIDGEWOOD
State	:	NY
Zip	:	11385-3949
Country	:	US
Telephone Number	:	718-576-3607
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2026
Last Update Date	:	06/08/2026

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