Provider Demographics
NPI:1851340400
Name:D'AMICO, MARYLOU (NP)
Entity Type:Individual
Prefix:
First Name:MARYLOU
Middle Name:
Last Name:D'AMICO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 IRVING AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1651
Mailing Address - Country:US
Mailing Address - Phone:315-478-1158
Mailing Address - Fax:315-478-3014
Practice Address - Street 1:739 IRVING AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1651
Practice Address - Country:US
Practice Address - Phone:315-478-1158
Practice Address - Fax:315-478-3014
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF420579363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY109419OtherPREFERRED CARE
NYP019420579OtherB/C B/S EXCELLUS
NYP019420579OtherB/C B/S EXCELLUS