Provider Demographics
NPI:1376891234
Name:MOMPREMIER, GUERLANDE (MA)
Entity Type:Individual
Prefix:
First Name:GUERLANDE
Middle Name:
Last Name:MOMPREMIER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3211 SW 66TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33023-3867
Mailing Address - Country:US
Mailing Address - Phone:954-512-7624
Mailing Address - Fax:
Practice Address - Street 1:3211 SW 66TH AVE
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33023-3867
Practice Address - Country:US
Practice Address - Phone:954-512-7624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA59700171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$OtherMA