Provider Demographics
NPI:1013414903
Name:HERIVAUX, MARIE A GERARDINE
Entity Type:Individual
Prefix:
First Name:MARIE A
Middle Name:GERARDINE
Last Name:HERIVAUX
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 1:10940 214TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-1915
Mailing Address - Country:US
Mailing Address - Phone:347-916-2422
Mailing Address - Fax:
Practice Address - Street 1:10940 214TH ST
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-1915
Practice Address - Country:US
Practice Address - Phone:347-916-2422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY27938861163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse