Provider Demographics
NPI:1639586712
Name:GATLIN, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GATLIN
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 1:166 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-3020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41-25TH 163RD STREET
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358
Practice Address - Country:US
Practice Address - Phone:718-571-8010
Practice Address - Fax:212-320-0304
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY662522163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse