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General NPI Number Information
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NPI Number | 1346308855
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Entity Type | Individual
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Provider Name | MARLENE QUILALA MD
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Gender | Female
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Dates
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Enumeration Date | 12/05/2006
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Last Update Date | 10/06/2016
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Provider Practice Location Address
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Address Line | 359 LAKEPORT BLVD
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City | LAKEPORT
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State | CA
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Zip | 95453-5412
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Country | US
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Telephone | 707-533-2740
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Fax | 707-263-5400
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Provider Business Mailing Address
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Address Line | 3605 BLACK ROCK RIDGE RD
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City | LAKEPORT
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State | CA
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Zip | 95453
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Country | US
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Telephone | 707-262-1634
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | A063667
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License Number State | CA
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