Provider Demographics
NPI:1154214682
Name:PORTAL CRESPO, MARIELYS
Entity type:Individual
Prefix:
First Name:MARIELYS
Middle Name:
Last Name:PORTAL CRESPO
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 1:16431 BLATT BLVD APT 102
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-1841
Mailing Address - Country:US
Mailing Address - Phone:714-476-4121
Mailing Address - Fax:
Practice Address - Street 1:1202 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3926
Practice Address - Country:US
Practice Address - Phone:253-441-4742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program