Provider Demographics
NPI:1619747813
Name:TSIDEMIDIS, MARY CANDIDA I
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CANDIDA
Last Name:TSIDEMIDIS
Suffix:I
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 1:56 KNOTT DR
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-4143
Mailing Address - Country:US
Mailing Address - Phone:516-676-5965
Mailing Address - Fax:
Practice Address - Street 1:295 7TH AVE
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:NY
Practice Address - Zip Code:11780-2436
Practice Address - Country:US
Practice Address - Phone:631-487-1627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336883-01163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice