Provider Demographics
NPI:1154381515
Name:SAN NICOLAS, MARLENE R (OD)
Entity type:Individual
Prefix:MISS
First Name:MARLENE
Middle Name:R
Last Name:SAN NICOLAS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6578
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96931-6578
Mailing Address - Country:US
Mailing Address - Phone:671-648-3350
Mailing Address - Fax:671-647-3537
Practice Address - Street 1:415 CHALAN SAN ANTONIO
Practice Address - Street 2:SUITE 111-113
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3620
Practice Address - Country:US
Practice Address - Phone:671-648-3350
Practice Address - Fax:671-647-3546
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUOL027152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist