Provider Demographics
NPI:1720116619
Name:MCCORMICK KUNIS, MARY ELLEN (MSED)
Entity Type:Individual
Prefix:MS
First Name:MARY ELLEN
Middle Name:
Last Name:MCCORMICK KUNIS
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:MS
Other - First Name:MARY ELLEN
Other - Middle Name:
Other - Last Name:MCCORMACK-KUNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:30 ITHACA ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-3427
Mailing Address - Country:US
Mailing Address - Phone:631-226-4361
Mailing Address - Fax:
Practice Address - Street 1:30 ITHACA ST
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-3427
Practice Address - Country:US
Practice Address - Phone:631-226-4361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist