Provider Demographics
NPI:1457748709
Name:MOMPREMIER, MARNELLE
Entity type:Individual
Prefix:MRS
First Name:MARNELLE
Middle Name:
Last Name:MOMPREMIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARNELLE
Other - Middle Name:
Other - Last Name:MOMPREMIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:112 UNION RD APT 2J
Mailing Address - Street 2:PO BOX 691
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NEW YORK
Mailing Address - Zip Code:10977
Mailing Address - Country:UM
Mailing Address - Phone:845-300-8422
Mailing Address - Fax:
Practice Address - Street 1:112 UNION RD APT 2J
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-3430
Practice Address - Country:US
Practice Address - Phone:845-300-8422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-23
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321485376G00000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No376G00000XNursing Service Related ProvidersNursing Home Administrator