Provider Demographics
NPI:1083263958
Name:STEWARD, MARLISE
Entity Type:Individual
Prefix:
First Name:MARLISE
Middle Name:
Last Name:STEWARD
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 1:3100 TELEGRAPH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3239
Mailing Address - Country:US
Mailing Address - Phone:800-607-6377
Mailing Address - Fax:
Practice Address - Street 1:3100 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3239
Practice Address - Country:US
Practice Address - Phone:800-607-6377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA811740163WC0200X
AZ196138163WF0300X
CA95001712367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WF0300XNursing Service ProvidersRegistered NurseFlight