Provider Demographics
NPI:1154804458
Name:VILLEGAS, MARINA
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:VILLEGAS
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 1:140 OAXACA LN
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-7019
Mailing Address - Country:US
Mailing Address - Phone:407-350-5904
Mailing Address - Fax:407-641-8319
Practice Address - Street 1:140 OAXACA LN
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34743-7019
Practice Address - Country:US
Practice Address - Phone:407-350-5904
Practice Address - Fax:407-641-8319
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12066310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility