Provider Demographics
NPI:1134904774
Name:SANON, MARLIE S (LPN)
Entity type:Individual
Prefix:
First Name:MARLIE
Middle Name:S
Last Name:SANON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1266 KEY MANOR LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-2231
Mailing Address - Country:US
Mailing Address - Phone:516-287-0281
Mailing Address - Fax:
Practice Address - Street 1:1266 KEY MANOR LN
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-2231
Practice Address - Country:US
Practice Address - Phone:516-287-0281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA100201164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty