Basic Information
Provider Information | |||||||||
NPI: | 1730703901 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DIDY | ||||||||
FirstName: | MARIE CYNTHIA | ||||||||
MiddleName: | ALICHA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1134 ROGERS AVE APT 2F | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112267164 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3476342185 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 585 SCHENECTADY AVE | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112031822 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7186045000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2020 | ||||||||
LastUpdateDate: | 06/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 336335 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Licensed Practical Nurse |   |
No ID Information.