Provider Demographics
NPI:1144776626
Name:HUCKABEY, MARLISE C (LVN)
Entity Type:Individual
Prefix:MRS
First Name:MARLISE
Middle Name:C
Last Name:HUCKABEY
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 1:31743 POPPY ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-8748
Mailing Address - Country:US
Mailing Address - Phone:951-852-5514
Mailing Address - Fax:
Practice Address - Street 1:41002 COUNTY CENTER DR STE 320
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-6027
Practice Address - Country:US
Practice Address - Phone:951-600-6355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN209162171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator