Provider Demographics
NPI:1851901011
Name:PREVOST, MARINE NELLY (AUD)
Entity type:Individual
Prefix:
First Name:MARINE
Middle Name:NELLY
Last Name:PREVOST
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:MARINE
Other - Middle Name:NELLY
Other - Last Name:CISMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:240 W THOMAS RD # 301
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4407
Mailing Address - Country:US
Mailing Address - Phone:604-406-7765
Mailing Address - Fax:602-294-5519
Practice Address - Street 1:2910 N 3RD AVE STE 330
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4434
Practice Address - Country:US
Practice Address - Phone:604-406-8811
Practice Address - Fax:602-406-8810
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDA12485231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist