Provider Demographics
NPI:1790349553
Name:ISME, MARIE YVANA (LPN)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:YVANA
Last Name:ISME
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 N 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85019-3206
Mailing Address - Country:US
Mailing Address - Phone:602-336-2920
Mailing Address - Fax:602-848-8472
Practice Address - Street 1:4510 N 37TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019-3206
Practice Address - Country:US
Practice Address - Phone:602-336-2920
Practice Address - Fax:602-848-8472
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP040670164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLP040670Medicaid