Provider Demographics
NPI:1588952972
Name:CANAVAN, MARYANNE COLLEEN (ANP)
Entity type:Individual
Prefix:MRS
First Name:MARYANNE
Middle Name:COLLEEN
Last Name:CANAVAN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1457 CLOVE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540-6437
Mailing Address - Country:US
Mailing Address - Phone:415-515-9748
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:ZUCKERMAN 4TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:212-639-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30 305725363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health