Healthcare Provider Details

I. General information

NPI: 1093255085
Provider Name (Legal Business Name): MARILLYN BAHAMON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 E COLORADO BLVD SUITE100
PASADENA CA
91107-6622
US

IV. Provider business mailing address

2555 E COLORADO BLVD SUITE100
PASADENA CA
91107-6622
US

V. Phone/Fax

Practice location:
  • Phone: 626-577-2261
  • Fax:
Mailing address:
  • Phone: 626-577-2261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number688936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: