Provider Demographics
NPI:1164120234
Name:MAUCK, EMILY (CPNP)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:MAUCK
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 W 4TH ST APT 5R
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-1058
Mailing Address - Country:US
Mailing Address - Phone:804-955-7675
Mailing Address - Fax:
Practice Address - Street 1:425 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-4012
Practice Address - Country:US
Practice Address - Phone:718-568-9220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA383529208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY383529OtherNEW YORK BOARD