Provider Demographics
NPI:1417585498
Name:MARAVILLA, TONYA MARIE (APSS)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:MARIE
Last Name:MARAVILLA
Suffix:
Gender:F
Credentials:APSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 E DIXIE AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-1162
Mailing Address - Country:US
Mailing Address - Phone:270-319-9899
Mailing Address - Fax:270-305-3253
Practice Address - Street 1:413 E DIXIE AVE STE 106
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1162
Practice Address - Country:US
Practice Address - Phone:270-319-9899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1170044175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist