Provider Demographics
NPI:1093752461
Name:ERNEST, MARYLOU LOUISE (NP)
Entity Type:Individual
Prefix:
First Name:MARYLOU
Middle Name:LOUISE
Last Name:ERNEST
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARYLOU
Other - Middle Name:LOUISE
Other - Last Name:LENHOFT;VICTORSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1635 DIVISADERO STREET, SUITE 625, BOX 1821
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 DIVISADERO ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3010
Practice Address - Country:US
Practice Address - Phone:415-353-7035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP6655363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03589ZMedicaid
CAZZZ03589ZMedicaid
CAZZZ03589ZMedicare PIN