Healthcare Provider Details

I. General information

NPI: 1033346747
Provider Name (Legal Business Name): ISLA STARR MARRERO NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2009
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 BRECKINRIDGE BLVD SUITE 415
DULUTH GA
30096-7612
US

IV. Provider business mailing address

PO BOX 5702
ATLANTA GA
31107-0702
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-8396
  • Fax:
Mailing address:
  • Phone: 716-830-4456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number171405
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number420933
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: