Provider Demographics
NPI:1598080749
Name:MINGOT, MARIE LUCIE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:LUCIE
Last Name:MINGOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:LUCIE
Other - Last Name:MINGOT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1060 E 105TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-3002
Mailing Address - Country:US
Mailing Address - Phone:347-713-5412
Mailing Address - Fax:
Practice Address - Street 1:1809 NOSTRAND AVE
Practice Address - Street 2:2 ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-7181
Practice Address - Country:US
Practice Address - Phone:718-421-4224
Practice Address - Fax:718-421-4774
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268164164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02386450Medicaid