Provider Demographics
NPI:1982924908
Name:QUACCOO, MARVA (LPN)
Entity Type:Individual
Prefix:MS
First Name:MARVA
Middle Name:
Last Name:QUACCOO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 BROADBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06620
Mailing Address - Country:US
Mailing Address - Phone:203-373-7559
Mailing Address - Fax:
Practice Address - Street 1:130 BROADBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-1121
Practice Address - Country:US
Practice Address - Phone:203-373-7559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234908164X00000X
CT234908164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse