Provider Demographics
NPI:1063655298
Name:HERBERT, MARC ALLEN (RN)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ALLEN
Last Name:HERBERT
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 DAVIES AVE
Mailing Address - Street 2:APARTMENT 4
Mailing Address - City:WEST HENRIETTA
Mailing Address - State:NY
Mailing Address - Zip Code:14586-8829
Mailing Address - Country:US
Mailing Address - Phone:585-354-5201
Mailing Address - Fax:
Practice Address - Street 1:385 DAVIES AVE
Practice Address - Street 2:APARTMENT 4
Practice Address - City:WEST HENRIETTA
Practice Address - State:NY
Practice Address - Zip Code:14586-8829
Practice Address - Country:US
Practice Address - Phone:585-354-5201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-17
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345236363L00000X
NY604642163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0200XNursing Service ProvidersRegistered NursePediatrics