Provider Demographics
NPI:1427421700
Name:MARQUEZ, STEPHANIE MARIE
Entity type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:MARQUEZ
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 1:259 61ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3713
Mailing Address - Country:US
Mailing Address - Phone:917-685-3631
Mailing Address - Fax:
Practice Address - Street 1:538 BROADHOLLOW RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3676
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:631-385-7795
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY378795537390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program