Healthcare Provider Details

I. General information

NPI: 1386002335
Provider Name (Legal Business Name): MARLYNE PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2016
Last Update Date: 07/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 ARIZONA ST
BISBEE AZ
85603-1804
US

IV. Provider business mailing address

1205 N F AVE
DOUGLAS AZ
85607-1920
US

V. Phone/Fax

Practice location:
  • Phone: 520-432-3309
  • Fax: 520-432-3717
Mailing address:
  • Phone: 520-364-6852
  • Fax: 520-364-4261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2014030930
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1036163
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: