Provider Demographics
NPI:1154798536
Name:THELOT-DOMINIQUE, MARIE-ANGE (LPN)
Entity type:Individual
Prefix:
First Name:MARIE-ANGE
Middle Name:
Last Name:THELOT-DOMINIQUE
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 1:11564 203RD ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2839
Mailing Address - Country:US
Mailing Address - Phone:347-617-8142
Mailing Address - Fax:
Practice Address - Street 1:11564 203RD ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-2839
Practice Address - Country:US
Practice Address - Phone:347-617-8142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY322101-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse