Provider Demographics
NPI:1083286264
Name:MARMOLEJO, EDITH (LVN)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:MARMOLEJO
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 SAN PASCUAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-3727
Mailing Address - Country:US
Mailing Address - Phone:626-491-9016
Mailing Address - Fax:
Practice Address - Street 1:1776 E CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3050
Practice Address - Country:US
Practice Address - Phone:323-374-6848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA707917164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse