Provider Demographics
NPI:1649754623
Name:TAGANAJAN, MARIELLE (NP-C)
Entity Type:Individual
Prefix:
First Name:MARIELLE
Middle Name:
Last Name:TAGANAJAN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14017 84TH DR APT 7H
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2423
Mailing Address - Country:US
Mailing Address - Phone:917-428-8096
Mailing Address - Fax:
Practice Address - Street 1:440 W 114TH ST STE 220
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1796
Practice Address - Country:US
Practice Address - Phone:212-523-9215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308118-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health