Provider Demographics
NPI:1821594953
Name:ST SURIN, MARIE ALBERTE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:ALBERTE
Last Name:ST SURIN
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 1:4107 GUNTHER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-2037
Mailing Address - Country:US
Mailing Address - Phone:321-745-5043
Mailing Address - Fax:
Practice Address - Street 1:127 W 25TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-7207
Practice Address - Country:US
Practice Address - Phone:212-533-3287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230778-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse