Provider Demographics
NPI:1215574801
Name:BARTHOLOMEW, MARLYN SUSAN VILLANUEVA
Entity Type:Individual
Prefix:
First Name:MARLYN SUSAN
Middle Name:VILLANUEVA
Last Name:BARTHOLOMEW
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 1:9087 ARROW RTE STE 246
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4488
Mailing Address - Country:US
Mailing Address - Phone:909-784-0620
Mailing Address - Fax:909-784-0617
Practice Address - Street 1:9087 ARROW RTE STE 246
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4488
Practice Address - Country:US
Practice Address - Phone:909-784-0620
Practice Address - Fax:909-784-0617
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008582363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily