Provider Demographics
NPI:1629337142
Name:FAY, MARY L (ANP-BC, DNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:FAY
Suffix:
Gender:F
Credentials:ANP-BC, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 RYAN STREET
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-2128
Mailing Address - Country:US
Mailing Address - Phone:516-364-2601
Mailing Address - Fax:516-364-2601
Practice Address - Street 1:300 COMMUNITY DRIVE
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030
Practice Address - Country:US
Practice Address - Phone:516-562-4392
Practice Address - Fax:516-562-3823
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303084-1363L00000X
NY329012-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner