Provider Demographics
NPI:1053056333
Name:PELLOT, MARINA ALEJANDRA
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:ALEJANDRA
Last Name:PELLOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13795 SW 36TH AVENUE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34473-6104
Mailing Address - Country:US
Mailing Address - Phone:352-533-2371
Mailing Address - Fax:
Practice Address - Street 1:13795 SW 36TH AVENUE RD STE 1
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34473-6104
Practice Address - Country:US
Practice Address - Phone:352-533-2371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL123456789OtherMEDICARE DIABETES PREVENTION PROGRAM