Provider Demographics
NPI:1760250211
Name:IBALDEZ, MARIVIC
Entity Type:Individual
Prefix:
First Name:MARIVIC
Middle Name:
Last Name:IBALDEZ
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 1:15 WHARF DR
Mailing Address - Street 2:
Mailing Address - City:BAY POINT
Mailing Address - State:CA
Mailing Address - Zip Code:94565-1358
Mailing Address - Country:US
Mailing Address - Phone:925-639-7594
Mailing Address - Fax:
Practice Address - Street 1:1340 ARNOLD DR
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4189
Practice Address - Country:US
Practice Address - Phone:925-639-7594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95197452163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse