Provider Demographics
NPI:1720692601
Name:LOUISE, MARIE
Entity type:Individual
Prefix:MS
First Name:MARIE
Middle Name:
Last Name:LOUISE
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 1:29 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-3256
Mailing Address - Country:US
Mailing Address - Phone:163-168-1771
Mailing Address - Fax:
Practice Address - Street 1:365 BROADWAY STE 4A
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2716
Practice Address - Country:US
Practice Address - Phone:163-608-8523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334710164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse