Provider Demographics
NPI:1396102224
Name:BACCHUS, MARILYN JOSEPH (RN)
Entity type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:JOSEPH
Last Name:BACCHUS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 HEATHCOTE RD
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2006
Mailing Address - Country:US
Mailing Address - Phone:516-587-4784
Mailing Address - Fax:
Practice Address - Street 1:23 BRITTANY CT
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3225
Practice Address - Country:US
Practice Address - Phone:631-834-5422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22-582918163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health