Provider Demographics
NPI:1790268803
Name:MARRERO, ELIA ENIS
Entity Type:Individual
Prefix:
First Name:ELIA
Middle Name:ENIS
Last Name:MARRERO
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 1:835 BERWICK DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-8308
Mailing Address - Country:US
Mailing Address - Phone:787-424-4118
Mailing Address - Fax:
Practice Address - Street 1:1631 E VINE ST STE J
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-3728
Practice Address - Country:US
Practice Address - Phone:407-329-3464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL171MOOOOOXMedicaid