Provider Demographics
NPI:1699257279
Name:GUZMAN, MAYBELLINE ELAINE
Entity type:Individual
Prefix:MRS
First Name:MAYBELLINE
Middle Name:ELAINE
Last Name:GUZMAN
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 1:20001 119TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11412-3514
Mailing Address - Country:US
Mailing Address - Phone:718-840-7000
Mailing Address - Fax:
Practice Address - Street 1:20001 119TH AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-3514
Practice Address - Country:US
Practice Address - Phone:718-840-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266707164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY32844Medicaid