Provider Demographics
NPI:1063765782
Name:GENNETEN SCOFFIN, MARILYN JANE
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:JANE
Last Name:GENNETEN SCOFFIN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARILYN
Other - Middle Name:JANE
Other - Last Name:GENNETTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:11325 BELLADONNA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-2923
Mailing Address - Country:US
Mailing Address - Phone:619-316-7077
Mailing Address - Fax:
Practice Address - Street 1:11325 BELLADONNA WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-2923
Practice Address - Country:US
Practice Address - Phone:619-316-7077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2377174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist