Provider Demographics
NPI:1720694417
Name:SMITH, MARIELLE KENYON
Entity Type:Individual
Prefix:
First Name:MARIELLE
Middle Name:KENYON
Last Name:SMITH
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 1:322 BLOOMFIELD ST APT 3
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-4823
Mailing Address - Country:US
Mailing Address - Phone:908-721-6683
Mailing Address - Fax:
Practice Address - Street 1:63 8TH ST
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-5022
Practice Address - Country:US
Practice Address - Phone:201-541-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program