Provider Demographics
NPI:1598702227
Name:FLANAGAN, MARISA G (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:G
Last Name:FLANAGAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 MARYS AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-5849
Mailing Address - Country:US
Mailing Address - Phone:845-331-8146
Mailing Address - Fax:845-331-3314
Practice Address - Street 1:117 MARYS AVE
Practice Address - Street 2:STE 201
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-5849
Practice Address - Country:US
Practice Address - Phone:845-331-8146
Practice Address - Fax:845-331-3314
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY427027163W00000X
NYF330823363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ20493Medicare UPIN
NY0666G1Medicare ID - Type Unspecified