Provider Demographics
NPI:1780227645
Name:PERNELL, SOMONE MONIQUE
Entity Type:Individual
Prefix:
First Name:SOMONE
Middle Name:MONIQUE
Last Name:PERNELL
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 1:456 BAYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2631
Mailing Address - Country:US
Mailing Address - Phone:631-609-5716
Mailing Address - Fax:
Practice Address - Street 1:456 BAYVIEW AVE
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2631
Practice Address - Country:US
Practice Address - Phone:631-609-5716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336566164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse