Provider Demographics
NPI:1285983296
Name:LARIVEAU-LAGREDELLE, MARIE-JEANNE GRADJA
Entity type:Individual
Prefix:MRS
First Name:MARIE-JEANNE
Middle Name:GRADJA
Last Name:LARIVEAU-LAGREDELLE
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 1:11555 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-3934
Mailing Address - Country:US
Mailing Address - Phone:516-782-3639
Mailing Address - Fax:
Practice Address - Street 1:11555 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-3934
Practice Address - Country:US
Practice Address - Phone:516-782-3639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY450512-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse