Provider Demographics
NPI:1629616412
Name:HULPA, MARCIE LYNN
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:LYNN
Last Name:HULPA
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 1:11812 GORHAM AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5491
Mailing Address - Country:US
Mailing Address - Phone:219-789-7789
Mailing Address - Fax:
Practice Address - Street 1:11812 GORHAM AVE APT 203
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5491
Practice Address - Country:US
Practice Address - Phone:219-789-7789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013351363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner