Provider Demographics
NPI:1700914835
Name:DOUGLAS, MARILYN MONIQUE (FNP)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:MONIQUE
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 LORRAINE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-3702
Mailing Address - Country:US
Mailing Address - Phone:914-924-2568
Mailing Address - Fax:
Practice Address - Street 1:560 1ST AVE
Practice Address - Street 2:TISCH 16 EAST
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-5630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF334986363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily