Healthcare Provider Details

I. General information

NPI: 1720573439
Provider Name (Legal Business Name): MARILYN TADIAMAN PUDOL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ROSECRANS AVE # 3230
EL SEGUNDO CA
90245-4749
US

IV. Provider business mailing address

3056 FLETCHER DR
LOS ANGELES CA
90065-2207
US

V. Phone/Fax

Practice location:
  • Phone: 323-628-8671
  • Fax:
Mailing address:
  • Phone: 323-256-2231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95008725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: