Provider Demographics
NPI:1467094821
Name:MARMOLEJOS, DIANA (NP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MARMOLEJOS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7307
Mailing Address - Country:US
Mailing Address - Phone:910-341-1540
Mailing Address - Fax:
Practice Address - Street 1:9101 OCEAN HWY E
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-7867
Practice Address - Country:US
Practice Address - Phone:910-371-0404
Practice Address - Fax:910-371-1005
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5016548363LF0000X
IN71009630A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300033418Medicaid