Provider Demographics
NPI:1932285137
Name:FUSSNER, MARLENE AGNES (NP)
Entity Type:Individual
Prefix:MS
First Name:MARLENE
Middle Name:AGNES
Last Name:FUSSNER
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 1:79-01 BROADWAY
Mailing Address - Street 2:MANAGED CARE, D1-01
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1329
Mailing Address - Country:US
Mailing Address - Phone:718-334-2508
Mailing Address - Fax:718-334-5990
Practice Address - Street 1:79-01 BROADWAY
Practice Address - Street 2:MANAGED CARE, D1-01
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1329
Practice Address - Country:US
Practice Address - Phone:718-334-2508
Practice Address - Fax:718-334-5990
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301987363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00330128Medicare ID - Type Unspecified
NY00246075Medicaid