Provider Demographics
NPI:1508045501
Name:ETIENNE, MARIE F
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:F
Last Name:ETIENNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:F
Other - Last Name:JACQUES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:51 SOUTHGATE RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:158 HORSESHOE RD
Practice Address - Street 2:
Practice Address - City:MILL NECK
Practice Address - State:NY
Practice Address - Zip Code:11765
Practice Address - Country:US
Practice Address - Phone:516-624-8797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199161-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
01474693OtherPROVIDER NUMBER