Provider Demographics
NPI:1902076573
Name:GORMAN, MARY ANN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3837 MARION CT
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-1869
Mailing Address - Country:US
Mailing Address - Phone:516-781-9347
Mailing Address - Fax:
Practice Address - Street 1:3837 MARION CT
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-1869
Practice Address - Country:US
Practice Address - Phone:516-781-9347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112723-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02744287Medicaid