Provider Demographics
NPI:1609288471
Name:DAVIS, MARJORIE (RN)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARJORIE
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSN,APRN,FNP-BC
Mailing Address - Street 1:407 E 4TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10553-1501
Mailing Address - Country:US
Mailing Address - Phone:718-683-4721
Mailing Address - Fax:
Practice Address - Street 1:407 E 4TH ST FL 2
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10553-1501
Practice Address - Country:US
Practice Address - Phone:718-683-4721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-28
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY669805163W00000X
NY347267363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF347267Medicaid