Provider Demographics
NPI:1447424650
Name:MARIANO, JUANITA AGUSTIN (APRN)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:AGUSTIN
Last Name:MARIANO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 GARTH RD STE 307
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77521-3156
Mailing Address - Country:US
Mailing Address - Phone:832-556-6046
Mailing Address - Fax:
Practice Address - Street 1:4201 GARTH RD STE 307
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521
Practice Address - Country:US
Practice Address - Phone:832-556-6046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-17
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003614363L00000X
TXAP133717363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX375608201Medicaid