Provider Demographics
NPI:1316481278
Name:MARMOLEJOS, MILDRED
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:MARMOLEJOS
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 1:434 S 5TH ST
Mailing Address - Street 2:APT 2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-1727
Mailing Address - Country:US
Mailing Address - Phone:917-692-7831
Mailing Address - Fax:
Practice Address - Street 1:434 S 5TH ST
Practice Address - Street 2:APT 2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-1727
Practice Address - Country:US
Practice Address - Phone:917-692-7831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212325174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist