Healthcare Provider Details

I. General information

NPI: 1427010883
Provider Name (Legal Business Name): MARILYN M. PATTILLO APRN GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 ROGGE LN
AUSTIN TX
78723-3640
US

IV. Provider business mailing address

1700 JACKSON HOLE CV
AUSTIN TX
78746-7634
US

V. Phone/Fax

Practice location:
  • Phone: 512-926-2070
  • Fax: 512-926-9570
Mailing address:
  • Phone: 512-451-4488
  • Fax: 512-453-2707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number424864
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: