Provider Demographics
NPI:1558924118
Name:MALLEBRANCHE, MARIE ROOSEVELT
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:ROOSEVELT
Last Name:MALLEBRANCHE
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 1:25742 145TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3315
Mailing Address - Country:US
Mailing Address - Phone:347-754-1221
Mailing Address - Fax:
Practice Address - Street 1:25742 145TH AVE
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-3315
Practice Address - Country:US
Practice Address - Phone:347-754-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY519543163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management