Provider Demographics
NPI:1699171629
Name:MARENGO, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MARENGO
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 1:28 MICHELE LN
Mailing Address - Street 2:
Mailing Address - City:YAPHANK
Mailing Address - State:NY
Mailing Address - Zip Code:11980-9632
Mailing Address - Country:US
Mailing Address - Phone:631-599-3404
Mailing Address - Fax:
Practice Address - Street 1:28 MICHELE LN
Practice Address - Street 2:
Practice Address - City:YAPHANK
Practice Address - State:NY
Practice Address - Zip Code:11980-9632
Practice Address - Country:US
Practice Address - Phone:631-599-3404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304378164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse