Provider Demographics
NPI:1366023665
Name:USTIAK, MARIANNA B (RN)
Entity Type:Individual
Prefix:
First Name:MARIANNA
Middle Name:B
Last Name:USTIAK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARIANNA
Other - Middle Name:B
Other - Last Name:USTIAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:1010 HAZEN ST
Mailing Address - Street 2:
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11370-1355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 HAZEN ST
Practice Address - Street 2:
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370-1355
Practice Address - Country:US
Practice Address - Phone:347-774-8976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY688017-01163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty