Basic Information
| Provider Information | |||||||||
| NPI: | 1023303872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLVERT | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLVERT | ||||||||
| OtherFirstName: | M. | ||||||||
| OtherMiddleName: | DENISE | ||||||||
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| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 126 MACDOUGAL ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112332625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3474140696 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 585 SCHENECTADY AVE | ||||||||
| Address2: | EMERGENCY DEPARTMENT | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112031809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186045000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2011 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 336686 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.