Provider Demographics
NPI:1316718091
Name:FORSON, MAVIS TEMAH
Entity type:Individual
Prefix:
First Name:MAVIS
Middle Name:TEMAH
Last Name:FORSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 MARY ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-3356
Mailing Address - Country:US
Mailing Address - Phone:347-527-8721
Mailing Address - Fax:
Practice Address - Street 1:6424 18TH AVE FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-3729
Practice Address - Country:US
Practice Address - Phone:347-830-2695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY778149163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse