Provider Demographics
NPI:1134473945
Name:MARYLES, FANNIE
Entity Type:Individual
Prefix:MRS
First Name:FANNIE
Middle Name:
Last Name:MARYLES
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 1:533 HAROLD ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5017
Mailing Address - Country:US
Mailing Address - Phone:718-370-8408
Mailing Address - Fax:
Practice Address - Street 1:533 HAROLD ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-5017
Practice Address - Country:US
Practice Address - Phone:718-370-8408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2307473174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist