Provider Demographics
NPI:1629505532
Name:BOUSQUET LA CORTE, MARIANELLA (SA-C)
Entity Type:Individual
Prefix:
First Name:MARIANELLA
Middle Name:
Last Name:BOUSQUET LA CORTE
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11301 NW 88TH TER
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2774
Mailing Address - Country:US
Mailing Address - Phone:305-905-2081
Mailing Address - Fax:
Practice Address - Street 1:11301 NW 88TH TER
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2774
Practice Address - Country:US
Practice Address - Phone:305-905-2081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17-305246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant