Provider Demographics
NPI:1588449532
Name:PADILLA, MARLISS
Entity type:Individual
Prefix:
First Name:MARLISS
Middle Name:
Last Name:PADILLA
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 ASCH LOOP
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-4033
Mailing Address - Country:US
Mailing Address - Phone:718-679-2099
Mailing Address - Fax:
Practice Address - Street 1:560 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-3715
Practice Address - Country:US
Practice Address - Phone:646-618-8913
Practice Address - Fax:718-766-2006
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY292846-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse