Provider Demographics
NPI:1417581539
Name:MARRONGELLE, DEREK (DACM, LAC, CCN)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MARRONGELLE
Suffix:
Gender:M
Credentials:DACM, LAC, CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 PINE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:ORWIGSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17961-9135
Mailing Address - Country:US
Mailing Address - Phone:570-617-9005
Mailing Address - Fax:
Practice Address - Street 1:16421 N TATUM BLVD STE 210
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3457
Practice Address - Country:US
Practice Address - Phone:570-617-9005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-010133171100000X
5063133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No133N00000XDietary & Nutritional Service ProvidersNutritionist