Healthcare Provider Details

I. General information

NPI: 1053971663
Provider Name (Legal Business Name): JENNIFER MARQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 DIAMOND HILL RD
WOONSOCKET RI
02895-1771
US

IV. Provider business mailing address

1625 DIAMOND HILL RD
WOONSOCKET RI
02895-1771
US

V. Phone/Fax

Practice location:
  • Phone: 401-762-1511
  • Fax: 401-762-1609
Mailing address:
  • Phone: 401-762-1511
  • Fax: 401-762-1609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number11728
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: