Healthcare Provider Details

I. General information

NPI: 1285200451
Provider Name (Legal Business Name): DAMARA VIVIAN MARSHALL AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 08/16/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W PROVIDENCE AVE
ORANGE CA
92868-3892
US

IV. Provider business mailing address

1301 W PROVIDENCE AVE
ORANGE CA
92868-3892
US

V. Phone/Fax

Practice location:
  • Phone: 714-639-4991
  • Fax:
Mailing address:
  • Phone: 714-639-4991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number14623
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number3609
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: