Provider Demographics
NPI:1205285061
Name:QUIAMBAO, MARIVIC (MA)
Entity type:Individual
Prefix:MRS
First Name:MARIVIC
Middle Name:
Last Name:QUIAMBAO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24411 GRAND CENTRAL PKWY
Mailing Address - Street 2:2FL
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-2333
Mailing Address - Country:US
Mailing Address - Phone:516-509-3998
Mailing Address - Fax:
Practice Address - Street 1:24411 GRAND CENTRAL PKWY
Practice Address - Street 2:2FL
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-2333
Practice Address - Country:US
Practice Address - Phone:516-509-3998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-11
Last Update Date:2016-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY550854111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist