Healthcare Provider Details

I. General information

NPI: 1093068090
Provider Name (Legal Business Name): MARLON BLANCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2012
Last Update Date: 02/10/2026
Certification Date: 02/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6517 TAFT ST
HOLLYWOOD FL
33024-4062
US

IV. Provider business mailing address

900 SW 104TH CT B103
MIAMI FL
33174-2660
US

V. Phone/Fax

Practice location:
  • Phone: 305-282-4063
  • Fax:
Mailing address:
  • Phone: 305-282-4063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number9250137
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: