Provider Demographics
NPI:1508021320
Name:MARLISSA, AUDY
Entity Type:Individual
Prefix:
First Name:AUDY
Middle Name:
Last Name:MARLISSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19431 RUE DE VALORE
Mailing Address - Street 2:#2G
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19431 RUE DE VALORE APT 2G
Practice Address - Street 2:
Practice Address - City:FOOTHILL RANCH
Practice Address - State:CA
Practice Address - Zip Code:92610-2308
Practice Address - Country:US
Practice Address - Phone:949-813-9210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN230605164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse