1588952972 NPI number — MRS. MARYANNE COLLEEN CANAVAN ANP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588952972 NPI number — MRS. MARYANNE COLLEEN CANAVAN ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANAVAN
Provider First Name:
MARYANNE
Provider Middle Name:
COLLEEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ANP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588952972
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1457 CLOVE VALLEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGRANGEVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12540-6437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-515-9748
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 YORK AVE
Provider Second Line Business Practice Location Address:
ZUCKERMAN 4TH FLOOR
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10065-6007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-639-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  30 305725 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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