Provider Demographics
NPI:1851733646
Name:SOUFFRANT, MARIE NINIVE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:NINIVE
Last Name:SOUFFRANT
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 1:491 METROPOLITAN AVE
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-3220
Mailing Address - Country:US
Mailing Address - Phone:617-365-4871
Mailing Address - Fax:
Practice Address - Street 1:491 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-3220
Practice Address - Country:US
Practice Address - Phone:617-365-4871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA67369164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse