Healthcare Provider Details

I. General information

NPI: 1104754019
Provider Name (Legal Business Name): MS. MARION VILLAHERMOSA HERMITANIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 LAVERNE DR
GREEN BAY WI
54311-5720
US

IV. Provider business mailing address

2259 RED TAIL GLN
DE PERE WI
54115-1631
US

V. Phone/Fax

Practice location:
  • Phone: 920-391-2410
  • Fax:
Mailing address:
  • Phone: 920-664-1575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number922209
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: