Provider Demographics
NPI:1083943286
Name:BAILEY, MAVIS M
Entity Type:Individual
Prefix:
First Name:MAVIS
Middle Name:M
Last Name:BAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MAVIS
Other - Middle Name:M
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:494 DUMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-5017
Mailing Address - Country:US
Mailing Address - Phone:718-385-4000
Mailing Address - Fax:
Practice Address - Street 1:11 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-5213
Practice Address - Country:US
Practice Address - Phone:516-385-5581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338877363L00000X
NY622224163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse