Provider Demographics
NPI:1750409538
Name:GANNON, MARYANN E (NP)
Entity type:Individual
Prefix:MRS
First Name:MARYANN
Middle Name:E
Last Name:GANNON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 LAKEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1101
Mailing Address - Country:US
Mailing Address - Phone:516-465-5400
Mailing Address - Fax:516-465-5454
Practice Address - Street 1:410 LAKEVILLE RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1101
Practice Address - Country:US
Practice Address - Phone:516-465-5400
Practice Address - Fax:516-465-5454
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271102163W00000X
NYF334186363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner