Provider Demographics
NPI:1538468194
Name:MONDESIR, MARIE PROPHETE
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:PROPHETE
Last Name:MONDESIR
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 1:11103 196TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2026
Mailing Address - Country:US
Mailing Address - Phone:718-468-5779
Mailing Address - Fax:
Practice Address - Street 1:11103 196TH ST
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-2026
Practice Address - Country:US
Practice Address - Phone:718-468-5779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287580-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse