Provider Demographics
NPI:1922553866
Name:ULYSSE, MARILINE
Entity Type:Individual
Prefix:
First Name:MARILINE
Middle Name:
Last Name:ULYSSE
Suffix:
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 1:2065 GRAND CONCOURSE
Mailing Address - Street 2:310
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-3847
Mailing Address - Country:US
Mailing Address - Phone:646-351-3582
Mailing Address - Fax:
Practice Address - Street 1:15813 72ND AVE
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1140
Practice Address - Country:US
Practice Address - Phone:718-380-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-21
Last Update Date:2016-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY731376174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid