Provider Demographics
NPI:1598429698
Name:ILLIG, MARLEYNA AUGUSTEINA
Entity Type:Individual
Prefix:
First Name:MARLEYNA
Middle Name:AUGUSTEINA
Last Name:ILLIG
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 1:4851 INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-6715
Mailing Address - Country:US
Mailing Address - Phone:303-425-0300
Mailing Address - Fax:
Practice Address - Street 1:4851 INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-6715
Practice Address - Country:US
Practice Address - Phone:303-425-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0009195172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker