Provider Demographics
NPI:1386002335
Name:PEREZ, MARLYNE
Entity Type:Individual
Prefix:
First Name:MARLYNE
Middle Name:
Last Name:PEREZ
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 1:1205 N F AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-1920
Mailing Address - Country:US
Mailing Address - Phone:520-364-6852
Mailing Address - Fax:520-364-4261
Practice Address - Street 1:108 ARIZONA ST
Practice Address - Street 2:
Practice Address - City:BISBEE
Practice Address - State:AZ
Practice Address - Zip Code:85603-1804
Practice Address - Country:US
Practice Address - Phone:520-432-3309
Practice Address - Fax:520-432-3717
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014030930133V00000X
AZ1036163133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered