Provider Demographics
NPI:1598909756
Name:SERPHY, MAYBELLINE
Entity Type:Individual
Prefix:
First Name:MAYBELLINE
Middle Name:
Last Name:SERPHY
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 1:11597 223RD ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11411-1232
Mailing Address - Country:US
Mailing Address - Phone:646-229-9790
Mailing Address - Fax:
Practice Address - Street 1:20514 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-2900
Practice Address - Country:US
Practice Address - Phone:718-528-5493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-30
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287539-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse