Healthcare Provider Details

I. General information

NPI: 1689311581
Provider Name (Legal Business Name): KENIA NATALIE LLIGUICOTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2022
Last Update Date: 05/13/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 ROUTE 70 E STE G101
MARLTON NJ
08053-2548
US

IV. Provider business mailing address

3801 MARQUETTE PL APT 2F
SAN DIEGO CA
92106-1027
US

V. Phone/Fax

Practice location:
  • Phone: 856-818-4020
  • Fax:
Mailing address:
  • Phone: 862-772-6260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL06696700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: