Provider Demographics
NPI:1326627696
Name:MAGASSOUBA, MARILYN E (LPN)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:E
Last Name:MAGASSOUBA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 IRON FORGE LN
Mailing Address - Street 2:
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553-1204
Mailing Address - Country:US
Mailing Address - Phone:347-557-6579
Mailing Address - Fax:845-245-4281
Practice Address - Street 1:604 IRON FORGE LN
Practice Address - Street 2:
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-1204
Practice Address - Country:US
Practice Address - Phone:347-557-6579
Practice Address - Fax:845-245-4281
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY323125164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse