Provider Demographics
NPI:1023389467
Name:ROUSSEAU, MARIE M
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:M
Last Name:ROUSSEAU
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 1:186 WELLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2010
Mailing Address - Country:US
Mailing Address - Phone:516-754-4298
Mailing Address - Fax:
Practice Address - Street 1:186 WELLINGTON RD
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-2010
Practice Address - Country:US
Practice Address - Phone:516-754-4298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305465164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse