Provider Demographics
NPI:1316178205
Name:MARS, SHERVONNE STACEY (LPN)
Entity Type:Individual
Prefix:MS
First Name:SHERVONNE
Middle Name:STACEY
Last Name:MARS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 MARTENSE ST
Mailing Address - Street 2:APT. 2A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-3260
Mailing Address - Country:US
Mailing Address - Phone:347-787-5040
Mailing Address - Fax:
Practice Address - Street 1:75 MARTENSE ST
Practice Address - Street 2:APT. 2A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-3260
Practice Address - Country:US
Practice Address - Phone:347-787-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290015-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse