Provider Demographics
NPI:1053113456
Name:BOUCICAUT, MARLEY BOUCICAUT
Entity type:Individual
Prefix:
First Name:MARLEY BOUCICAUT
Middle Name:
Last Name:BOUCICAUT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 SAN MARCO CIR APT 102
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33403-1845
Mailing Address - Country:US
Mailing Address - Phone:929-288-7966
Mailing Address - Fax:
Practice Address - Street 1:6424 18TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-3729
Practice Address - Country:US
Practice Address - Phone:917-830-2695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRN9658465163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse