Provider Demographics
NPI:1629603600
Name:PONCE DE LEON, MARILYN DENISE (SCHOOL NURSE)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:DENISE
Last Name:PONCE DE LEON
Suffix:
Gender:F
Credentials:SCHOOL NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 SHELL BLVD APT 102
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-2550
Mailing Address - Country:US
Mailing Address - Phone:909-744-2921
Mailing Address - Fax:650-655-3394
Practice Address - Street 1:1170 CHESS DR
Practice Address - Street 2:
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-1107
Practice Address - Country:US
Practice Address - Phone:650-638-2973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA160250571163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool