Provider Demographics
NPI:1629470505
Name:TALIBONG, MARIELLA LISET (LPN)
Entity Type:Individual
Prefix:
First Name:MARIELLA
Middle Name:LISET
Last Name:TALIBONG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:HILLBURN
Mailing Address - State:NY
Mailing Address - Zip Code:10931-2001
Mailing Address - Country:US
Mailing Address - Phone:845-641-2717
Mailing Address - Fax:
Practice Address - Street 1:1 LAKE ST
Practice Address - Street 2:
Practice Address - City:HILLBURN
Practice Address - State:NY
Practice Address - Zip Code:10931-2001
Practice Address - Country:US
Practice Address - Phone:845-641-2717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303528-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse