Provider Demographics
NPI:1316041528
Name:CONNER, MARILYN F (CANP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:F
Last Name:CONNER
Suffix:
Gender:F
Credentials:CANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 N COUNTRY RD
Mailing Address - Street 2:JOHN T MATHER HOSPITAL
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2119
Mailing Address - Country:US
Mailing Address - Phone:631-476-2715
Mailing Address - Fax:
Practice Address - Street 1:82 MIDDLE COUNTRY ROAD
Practice Address - Street 2:THE ELSIE OWENS N BROOKHAVEN HEALTH CENTER AT CORAM
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727
Practice Address - Country:US
Practice Address - Phone:631-854-2301
Practice Address - Fax:631-854-2104
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3007001363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01770245Medicaid
96N371Medicare UPIN
P13720Medicare UPIN