Healthcare Provider Details

I. General information

NPI: 1962080366
Provider Name (Legal Business Name): YENNY COROMOTO MARQUEZ DE GUETHON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 NE 12TH AVE
POMPANO BEACH FL
33064-6109
US

IV. Provider business mailing address

4050 NE 12TH AVE
POMPANO BEACH FL
33064-6109
US

V. Phone/Fax

Practice location:
  • Phone: 954-548-7283
  • Fax:
Mailing address:
  • Phone: 954-548-7283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-108464
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: