Provider Demographics
NPI:1124207386
Name:MARIN, ILEANA DESPINA (LPN)
Entity Type:Individual
Prefix:
First Name:ILEANA
Middle Name:DESPINA
Last Name:MARIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 S J STOCK RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-7012
Mailing Address - Country:US
Mailing Address - Phone:520-295-2503
Mailing Address - Fax:520-295-2676
Practice Address - Street 1:HWY 86 AND TOPAWA ROAD
Practice Address - Street 2:
Practice Address - City:SELLS
Practice Address - State:AZ
Practice Address - Zip Code:85634
Practice Address - Country:US
Practice Address - Phone:520-383-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 224671164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse