Provider Demographics
NPI:1073942553
Name:PERSONNA, MARIE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:PERSONNA
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 TEHAMA ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-2112
Mailing Address - Country:US
Mailing Address - Phone:617-388-4066
Mailing Address - Fax:
Practice Address - Street 1:28 TEHAMA ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-2112
Practice Address - Country:US
Practice Address - Phone:617-388-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296179164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse