Healthcare Provider Details

I. General information

NPI: 1497153274
Provider Name (Legal Business Name): MARILYN STATON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2014
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 DOUGLAS ST APT 34
HOMOSASSA FL
34446-3958
US

IV. Provider business mailing address

22 GOLFVIEW DR
HOMOSASSA FL
34446-4219
US

V. Phone/Fax

Practice location:
  • Phone: 989-400-7541
  • Fax:
Mailing address:
  • Phone: 989-400-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberFK0578229
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9108371
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: