Provider Demographics
NPI:1629688734
Name:CORONADO, MARISSA (DEM)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:CORONADO
Suffix:
Gender:F
Credentials:DEM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10886 S SHILLING AVE APT 2034
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10886 S SHILLING AVE APT 2034
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4334
Practice Address - Country:US
Practice Address - Phone:510-305-5460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175M00000XOther Service ProvidersMidwife, Lay