Provider Demographics
NPI:1215538988
Name:CALDEVILLA, MARLO
Entity Type:Individual
Prefix:
First Name:MARLO
Middle Name:
Last Name:CALDEVILLA
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 1:4710 N HABANA AVE STE 307
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7151
Mailing Address - Country:US
Mailing Address - Phone:813-874-2000
Mailing Address - Fax:
Practice Address - Street 1:4710 N HABANA AVE STE 307
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7151
Practice Address - Country:US
Practice Address - Phone:813-874-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-07
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11017889363LP0200X
FL9436825163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse