Provider Demographics
NPI:1376282475
Name:TAVARES, MARIELLE
Entity Type:Individual
Prefix:
First Name:MARIELLE
Middle Name:
Last Name:TAVARES
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 1:5743 VENTURA CANYON AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY GLEN
Mailing Address - State:CA
Mailing Address - Zip Code:91401-4533
Mailing Address - Country:US
Mailing Address - Phone:310-948-6356
Mailing Address - Fax:
Practice Address - Street 1:808 W 58TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-3632
Practice Address - Country:US
Practice Address - Phone:310-948-6356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020541363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty