Provider Demographics
NPI:1750791612
Name:ARCHIBALD, MARILYN IV (REGISTERED NURSE)
Entity type:Individual
Prefix:MISS
First Name:MARILYN
Middle Name:
Last Name:ARCHIBALD
Suffix:IV
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1039 E 84TH ST
Mailing Address - Street 2:FLOOR 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4227
Mailing Address - Country:US
Mailing Address - Phone:718-304-4673
Mailing Address - Fax:
Practice Address - Street 1:13 CLEVELAND ST
Practice Address - Street 2:VALLEY STREAM
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-6003
Practice Address - Country:US
Practice Address - Phone:516-823-0739
Practice Address - Fax:516-823-1550
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22 683025163W00000X
NY22. 683025163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRN NO. 22 683025OtherREGISTERED NURSE