Provider Demographics
NPI:1083260780
Name:PATRICK, MARCI DEANNA
Entity Type:Individual
Prefix:
First Name:MARCI
Middle Name:DEANNA
Last Name:PATRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARCI
Other - Middle Name:DEANNA
Other - Last Name:FLYNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 W LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-2015
Mailing Address - Country:US
Mailing Address - Phone:209-663-2302
Mailing Address - Fax:
Practice Address - Street 1:441 S HAM LN STE A
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3525
Practice Address - Country:US
Practice Address - Phone:209-224-8940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-18
Last Update Date:2019-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA180380164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse