Provider Demographics
NPI:1053633586
Name:GORE, MARCIA DENA
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:DENA
Last Name:GORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24102 149TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3220
Mailing Address - Country:US
Mailing Address - Phone:718-528-6157
Mailing Address - Fax:
Practice Address - Street 1:24102 149TH AVE
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-3220
Practice Address - Country:US
Practice Address - Phone:718-528-6157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY501131163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse