Provider Demographics
NPI:1487003117
Name:CANDY, MARIE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:CANDY
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 1:9345 202ND ST
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-3016
Mailing Address - Country:US
Mailing Address - Phone:917-651-6325
Mailing Address - Fax:
Practice Address - Street 1:93-45 202 ST
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423
Practice Address - Country:US
Practice Address - Phone:917-651-6325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY325424-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYKE85628SMedicaid