Provider Demographics
NPI:1073955704
Name:FORD-MIMMS, MARISA EMMA
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:EMMA
Last Name:FORD-MIMMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:EMMA
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:22 DAVIS ST.
Mailing Address - Street 2:APT. 2
Mailing Address - City:BEACON
Mailing Address - State:NY
Mailing Address - Zip Code:12508
Mailing Address - Country:US
Mailing Address - Phone:845-549-9982
Mailing Address - Fax:
Practice Address - Street 1:9 RESERVOIR RD
Practice Address - Street 2:
Practice Address - City:TAWLING
Practice Address - State:NY
Practice Address - Zip Code:12564
Practice Address - Country:US
Practice Address - Phone:845-855-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305728-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse