Provider Demographics
NPI:1447834239
Name:ENRIQUEZ, MADELYN MARIE
Entity type:Individual
Prefix:
First Name:MADELYN
Middle Name:MARIE
Last Name:ENRIQUEZ
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 1:5410 15TH AVE
Mailing Address - Street 2:ACTIVE
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219
Mailing Address - Country:US
Mailing Address - Phone:718-436-0771
Mailing Address - Fax:
Practice Address - Street 1:705 AV X
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235
Practice Address - Country:US
Practice Address - Phone:929-312-1017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-08
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNXU516631820Medicaid