Provider Demographics
NPI:1255566329
Name:ITZKOWITZ, MARY ELLEN (BS)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:ITZKOWITZ
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 BYRD ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-5503
Mailing Address - Country:US
Mailing Address - Phone:516-766-8923
Mailing Address - Fax:516-766-8923
Practice Address - Street 1:159 BYRD ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-5503
Practice Address - Country:US
Practice Address - Phone:516-766-8923
Practice Address - Fax:516-766-8923
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker