Provider Demographics
NPI:1588931752
Name:FUNIESTAS, MARVIN (LVN)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:FUNIESTAS
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9328 ELK GROVE BLVD
Mailing Address - Street 2:STE 105-126
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-5063
Mailing Address - Country:US
Mailing Address - Phone:916-718-7745
Mailing Address - Fax:
Practice Address - Street 1:9328 ELK GROVE BLVD
Practice Address - Street 2:STE 105-126
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-5063
Practice Address - Country:US
Practice Address - Phone:916-718-7745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261947164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse