Provider Demographics
NPI:1124879002
Name:DIZON, MARYANN LUMBA (RN)
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:LUMBA
Last Name:DIZON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11072
Mailing Address - Street 2:
Mailing Address - City:YIGO
Mailing Address - State:GU
Mailing Address - Zip Code:96929-0072
Mailing Address - Country:US
Mailing Address - Phone:671-480-5534
Mailing Address - Fax:
Practice Address - Street 1:498 CHALAN PALOSYO
Practice Address - Street 2:
Practice Address - City:AGANA HEIGHTS
Practice Address - State:GU
Practice Address - Zip Code:96910-6427
Practice Address - Country:US
Practice Address - Phone:671-475-5760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95215094163W00000X
GURX0708163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse