Provider Demographics
NPI:1770880643
Name:LOUIS, YANIQUE
Entity type:Individual
Prefix:
First Name:YANIQUE
Middle Name:
Last Name:LOUIS
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 1:8825 163RD ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-4046
Mailing Address - Country:US
Mailing Address - Phone:718-739-0045
Mailing Address - Fax:
Practice Address - Street 1:100 PORTER ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-2833
Practice Address - Country:US
Practice Address - Phone:617-259-7032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-11
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY636173163W00000X
MA2267342363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse