Provider Demographics
NPI:1851083281
Name:SANTA ELENA, MARIENNE ALYSSA (OD)
Entity Type:Individual
Prefix:DR
First Name:MARIENNE
Middle Name:ALYSSA
Last Name:SANTA ELENA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2732 E MAIN
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3164
Mailing Address - Country:US
Mailing Address - Phone:503-719-1213
Mailing Address - Fax:
Practice Address - Street 1:2732 E MAIN
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3164
Practice Address - Country:US
Practice Address - Phone:253-770-2732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD61449531152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist